Class I Recall of Ventana Medical Systems Detection Kits

PUBLISHED: Oct 1, 2018
Relevant to: Clinical Lab, Critical Access Hospitals, Hospitals

Ventana Medical Systems is recalling the detection kits described below due to leaking and sticking of reagent dispensers which could cause a test result to indicate the absence of a biomarker when, in fact, the person does express the biomarker (false negative). A false negative may result in inappropriate treatment or delay in treatment. The use of the affected product may cause serious adverse health consequences. There are no deaths or serious health problems that have been reported. The U.S. Food and Drug Administration (FDA) has classified this as a Class I recall, the most serious type of recall: use of these devices may cause serious injuries or death.

Recalled Product

  • Name: Detection kits using the FLO-LOK III Dispenser
  • Serial Numbers: Full List of Affected Products
  • Manufacturing Dates: May 16, 2017 to December 12, 2017
  • Distribution Dates: July 24, 2017 to March 29, 2018
  • Devices recalled in the U.S: 38,000 kits (number of dispensers varies per kit)

The detection kits contain reagents used during immunohistochemistry (IHC) lab tests. The dispensers release the staining reagents that change color to indicate biomarkers. Biomarkers are used as an aid in the diagnosis and management of patient treatment for many health conditions, including cancer. The results can also indicate whether a patient is likely to benefit from certain drugs.

On August 2, 2018, Ventana Medical Systems sent Field Safety Notices to all affected customers and asked them to:

  • Discontinue the use of all affected dispensers for clinical testing from “Previously Communicated Lots
  • Perform a retrospective review and re-testing (if applicable) of clinical cases involving an affected dispenser lot that did not include a same-slide control. The ultimate scope of the re-testing is at the medical discretion of each laboratory in accordance with local hospital/laboratory procedures and policies, but should include at a minimum those assays used as the sole determinant for patient therapy or decision-making (e.g. HER2, ER/PR, ALK, PD-L1 (SP142), PD-L1(SP263) and C-Kit(9.7)).

Review/re-testing is typically not necessary for:

  • laboratories utilizing same-slide controls as routine practice.
  • assays in which a biologic internal control is always present (e.g. HER2 Dual ISH).
  • individual cases containing internal biologic controls.
  • individual cases that were already re-tested in association with the original RTD field notification and re-testing recommendation (FSN-RTD-2017-001).

Contact Ventana Medical Systems for further instructions relating to temporary replacement possibilities.

Follow the link below for additional information.

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