WARNING LETTER
Beckman Coulter Inc.
MARCS-CMS 678042 —
March 15, 2024
Delivery Method:
United Parcel Service
Product:
Medical Devices
Recipient:
Recipient Name
Julie Sawyer Montgomery
Recipient Title
President, Diagnostics Division (Brea, CA)
Beckman Coulter Inc.
250 S. Kraemer Blvd.
Brea
,
CA
92821
United States
Issuing Office:
Division of Medical Device and Radiological Health Operations Central
United States
WARNING LETTER
CMS # 678042
March 15, 2024
Dear Ms. Montgomery:
During an inspection of your firm located at 1000 Lake Hazeltine Drive, Chaska, MN, from November 1, 2023, through December 11, 2023, an investigator from the United States Food and Drug Administration (FDA) determined that your firm is a manufacturer of DxI 9000 Access Immunoassay analyzer instrument system and assays. Under section 201(h) of the Federal Food, Drug, and Cosmetic Act (the Act), 21 U.S.C. § 321(h), these products are devices because they are intended for use in the diagnosis of disease or other conditions or in the cure, mitigation, treatment, or prevention of disease, or to affect the structure or any function of the body.
This inspection revealed that these devices are adulterated within the meaning of section 501(h) of the Act, 21 U.S.C. § 351(h), in that the methods used in, or the facilities or controls used for, their manufacture, packing, storage, or installation are not in conformity with the current good manufacturing practice requirements of the Quality System regulation found at Title 21, Code of Federal Regulations (CFR), Part 820. We received a response January 01, 2024, and February 15, 2024, from Kathleen P. Orland, concerning our investigator’s observations noted on the Form FDA 483, List of Inspectional Observations (FDA 483) that was issued on December 11, 2023. We address the response below, in relation to each of the noted violations. These violations include, but are not limited to, the following:
1. Failure to adequately establish and maintain procedures for risk analysis, as required by 21 CFR 820.30(g). Specifically, your firm's primary risk control procedure "Product Safety Risk Management," GLB-QS-PCD-0047, Revision 15.3, Dated 17Aug 2023, states that it is compliant with ISO 14971:2019 and EN 14971:2019 + A11:2021, and defines the
(b)(4)
severity of harm categories as:
(b)(4)
. While the definitions for
(b)(4)
and
(b)(4)
as outlined in Appendix 9.1 are clear, the definitions of
(b)(4)
,
(b)(4)
, and
(b)(4)
are insufficient. Based on your firm’s definitions,
(b)(4)
should be classified as
(b)(4)
. Meanwhile,
(b)(4)
should be classified as
(b)(4)
.
(b)(4)
should never be chosen because an injury either would, or would not, require
(b)(4)
to preclude
(b)(4)
. There is no foreseeable circumstance where an injury could be recovered from without the need for
(b)(4)
or would be categorized as
(b)(4)
.
Severity Rating has been incorrectly selected for many assays’ false result failure modes. For example,
A. Your firm’s “Immunoassay Instruments Product Safety Reference (PSR),” GLB-QS-TMP-0005, Revision 6.17, effective date: 10/11/2022, includes the HBs Ag false/high positive reported failure mode inappropriately rated as
(b)(4)
. Risks associated with false negative HBs Ag, HBc IgM, and HBc Ab may be more clinically serious and include missed diagnosis of acute HBV infection (HBc IgM and HBc Total) and chronic HBV infection (HBs Ag). For the patient, this increases risk of
(b)(4)
including
(b)(4)
, HBs Ag in the mother is also used to determine the timing of hepatitis B vaccination or the need for hepatitis B immune globulin (HBIG) in the infant to prevent vertical transmission of HBV. From a public health standpoint, a false negative result on any of these assays also leads to increased risk of HBV transmission to others. Because the risk of false negatives in these assays include
(b)(4)
to the patient and others, your firm’s Severity Rating for the HBc IgM is determined to be incorrectly evaluated as
(b)(4)
.
Finally, your firm has failed to use Semi-Quantitative Ranges to estimate the Occurrence Rating when data is available, as indicated by GLB-QS-PCD-0047. In “Post Launch Risk Assessment for short pneumatic tubing part number
(b)(4)
”, Revision 1.7, date of assessment 03/10/2020, Section V. your firm states that "Out of
(b)(4)
instruments,
(b)(4)
% of the instruments are suspected to be built with incorrect tubing length which equates to
(b)(4)
instruments” and that “it is considered that the entire
(b)(4)
impacted instruments could potentially malfunction or fail. There has been one reported failure till date.” As the potential hazards identified are described as “leading to emergency service calls and the end effect is equipment downtime causing a delay in reporting patient results”, your firm has data to estimate the occurrence of the hazard and the hazardous situation. Your firm’s use of Qualitative occurrence ratings and
(b)(4)
rating as “
(b)(4)
” is in deviation to your firm’s procedures, as your firm has data available to estimate occurrence of the hazardous situation and instead rate the occurrence of the hazardous situation as “
(b)(4)
” per the semi-quantitative ranges appendix.
B. Your firm’s “AccuTnI, hsTnI, and AccuTnI+3Product [sic] Safety Reference (PSR),” Revision 2.16, Dated 08 Feb 2023 covers the assay-specific Harms identified for the family
of Troponin I assays. The Harm section of this PSR addressing the specific Hazardous Situation false negative/low cTn states “False negative can lead to missed diagnosis of
(b)(4)
. Inappropriate discharge of affected patient puts patient at
(b)(4)
”. The conclusion of severity of harm as
(b)(4)
has been incorrectly assessed since the severity of harm for false negative cTn test results would be classified as
(b)(4)
. Similarly, a false positive cTn would result in a worst-case scenario puts patients
(b)(4)
and severity of harm would again be
(b)(4)
. A similar conclusion can be made for delay in test results for cTn. The cTn is a time sensitive analyte since critical decisions need to be made rapidly in the
(b)(4)
. Such a delay could lead to missed diagnosis of
(b)(4)
and
(b)(4)
. Thus, severity of harm classification of delay in results would also be considered
(b)(4)
.
C. Your firm’s PSR “Digoxin Product Safety Reference (PSR),” Revision 1.17, Dated 23 Jun 2023 states in a delay of DIG TDM results: Health consequences as a result of not receiving necessary treatment may lead to
(b)(4)
. However, risk assessment includes the conclusion of
(b)(4)
severity of harm due to delay in obtaining Digoxin therapeutic drug monitoring (DIG TDM) results. The severity of harm of delay in results for DIG TDM would be
(b)(4)
. In addition, both false positive and false negative test results also appear to be under classified. Based on PSR Digoxin reference document your firm considers severity of harm for false positive (FP) results as
(b)(4)
and false negative results as
(b)(4)
.
i. FP results could lead to mistreatment due to sub-therapeutic dosing based on falsely elevated digoxin levels. Such undertreatment could lead to
(b)(4)
. Additionally, undertreatment for
(b)(4)
could lead to the development of
(b)(4)
. Such severity of harm would be considered
(b)(4)
.
ii. FN results could lead to over-dosing by the clinician due to false low drug levels, leading to DIG toxicity. There are many different complications of digoxin toxicity ranging from mild to severe; the most severe are
(b)(4)
. Thus, worst case scenario of FN DIG TDM would be considered
(b)(4)
as well.
The responses dated 01/03/2024 and 2/15/2024 are not adequate. Your firm has not provided proposed updates or justification to address use of “
(b)(4)
” Severity rating. Your firm has not provided justification or updated Severity ratings for the common failure modes for the PMA devices under review. Your firm has not proposed corrective actions or justification for the use of Qualitative occurrence ratings when data is available to use the Semi-quantitative Occurrence ratings. Nor has your firm provided a systemic review and corrective actions based on the Observation.
2. Failure to adequately establish procedures for corrective and preventative actions, as required by 21 CFR 820.100(a). For example,
A. Your firm’s CAPA procedure and related standard operating procedures have not been adequately established to analyze quality data to identify existing and potential causes of nonconforming product or other quality problems.
i. Your procedure, “Manufacturing Non-Conformance CAPA Eligibility,” GLB-QS-WI-0020, Revision 3.1, does not provide uniform process or includes clearly defined criteria to escalate events such as nonconformances to a CAPA.
a. The processes for nonconformance risk assessment of single nonconformances has not been developed, nor has it adequately defined actions to be taken for different levels of risk and correcting problems and preventing them from recurring.
b. Procedure states in part, “… Alternatively, on a
(b)(4)
basis, review manufacturing nonconformance data against defined trigger limits.” However, there is no further definition on how to separate the data, if any trigger limits are used, what cut-off value was set for high volume complaints, and what scale is used for frequency/occurrence ratings for high and low value nonconformances. The process on how the nonconformance trending is run is not described in procedure to ensure it is done in a uniform manner.
c. Severity assigned to nonconformances that have not been released to the field is not adequately defined. The information is used to determine the severity of these nonconformance trends is not adequately described.
ii. Your procedure “Complaint Trending,” GLB-QS-WI-0009, Revision 11.0, does not provide a process to determine whether a CAPA Request should be opened for a noted complaint trend.
a.
(b)(4)
on the “
(b)(4)
Trend” sheet of the “Trending Workbook v1.3” incorrectly calculates
(b)(4)
, or
(b)(4)
, for the subsequent occurrence analysis.
b.
(b)(4)
chart limits are recalculated for each category
(b)(4)
. You have not adequately documented justification on why this is a valid statistical technique.
c. Each “
(b)(4)
” complaint line item is assigned a
(b)(4)
for each of the last
(b)(4)
, depending on if it exceeded
(b)(4)
calculated values. However, there is no documentation on how these
(b)(4)
were originally established.
iii. Your procedure “Complaint Handling and Investigation,” GLB-QS-PCD-0018, Revision 19.1, the only reference to CAPA escalation is through the procedure “Complaint Trending,” GLB-QS-WI-0009. Your procedures do not define a method to escalate a single complaint record to the CAPA Request process.
B. Your firm has not verified and validated corrective actions to ensure such actions are effective and do not adversely affect the finished device.
i. A corrective action was taken under Design Change Plan, “DxI 9000
(b)(4)
DCP,” MDF2023-3479, Version 1.1, when
(b)(4)
PCBs failed in manufacturing testing and were associated with the shorting of the PCBs. Specifically,
(b)(4)
can cause a short that leads to the
(b)(4)
, as described in NC-INT-59380. Investigation noted that part number
(b)(4)
PCB,
(b)(4)
introduced the opportunity for the board to short due to the
(b)(4)
used. Corrective actions taken included,
a) A design change from a
(b)(4)
to a
(b)(4)
.
b) Revisions to manufacturing process procedures to ensure:
1. correct
(b)(4)
and
(b)(4)
is utilized.
2.
(b)(4)
is utilized on
(b)(4)
.
In addition, corrections were made to nonconforming product by performing rework on product at your facility.
Per the associated “Design Change Plan,” template, GLB-QS-TMP-0017, Revision 10.1, Dated 03 Aug 2023, if the design change type is “
(b)(4)
,” section
(b)(4)
. This section includes review of the design inputs, risk analysis and review, verification plan, validation plan and design review plan. There are no further requirements to ensure all corrective actions are performed as required (updating manufacturing procedures, training, updating design risk analysis, updating DMR, etc.). There is no assurance that actions taken were effective and did not adversely affect finished device.
The investigation performed as part of nonconformances NC-INT-59380 and NC-INT-59382 does not adequately address the scope and impact of the
(b)(4)
on part number
(b)(4)
and how it, may or may not impact other devices among other things. In addition, the root cause has not been adequately identified as it relates to device design issue (design change to
(b)(4)
), design verification and validation, design transfer and design reviews as it relates to components used to
(b)(4)
Update for obsolete Parts) to analyzer.
ii. CAPA-000604 was opened on 01 Jun 2021 to address the assay carryover issue noted after high hsTnI results. This CAPA resulted in
(b)(4)
for the
(b)(4)
of the DxI 600/800 Analyzer, Access 2 Analyzer and the
(b)(4)
for the associated troponin assay. In addition, labeling updates were made as part of corrective actions. The CAPA was closed without verifying and validating that the corrective actions are effective and do not adversely affect the finished device.
The adequacy of your firm’s response letter dated 1/03/2024 and response update dated 2/15/2024, cannot be determined at this time. The response notes that your firm is taking corrective actions to address the issue of quality data analysis and trending, revising risk analysis in trending and CAPA initiation. These actions encompass conducting retrospective reviews, revising mechanisms by which CAPAs are opened, and revising CAPA procedures to align with local and global procedures and training affected employees. Additionally, corrective actions are being handled through a CAPA for each respective observation to decide if further remediation actions are necessary. However, the response does not furnish specific information regarding the results or outcomes of these corrective actions as many remain ongoing. In addition, your firm’s response does not adequately address the failure to verify and validate corrective actions taken as part of a design change to correct and prevent their recurrence and ensure they do not have an adverse impact on the finished product.
3. Failure to adequately establish procedures to control product that does not conform to specified requirements, as required by 21 CFR 820.90(a). Specifically,
A. Your procedure “
(b)(4)
NC Module Management,” CHA-OPS-WI-0094, Revision 8, Dated 18 July 2023, has not been adequately established to describe how the “Problem Data Collection Sheet (PDCS)” form will be utilized to control product that does not conform to specified requirements to include record keeping requirements. The PDCS form is completed when non-conforming product is identified in the manufacturing area, as a precursor to
(b)(4)
review, and which may contain an initial evaluation and investigation of the nonconforming product. However, the procedure lacks adequate description for the use of PDCS form in conjunction with CIA Nonconforming Product,” CIA-QRA-WI-0001, Revision 17.1, Dated 18 Sep 2023 to ensure nonconforming components are evaluated, investigated, segregated, and dispositioned with the signature of the authorizing individual.
B. Your procedure “Triage Management Standard Work,” Version 1.2, Dated 10/16/2023, defines the form for your “Part Tracking Sheet.” The form is used on nonconforming product that has been reviewed and/or investigated in
(b)(4)
and had no problem found. However, your procedures do not describe when this disposition should be chosen in the Material Review Board and who has the responsibility to complete this review and approval.
C. Your procedure “
(b)(4)
NC Module Management,” CHA-OPS-WI-0094, Revision 8, Dated 18 Jul 2023, and procedure “CIA Nonconforming Product,” CIA-QRA-WI-0001, Revision 17.1, Dated 18 Sep 2023, have conflicting definitions of “
(b)(4)
.”
(b)(4)
is one of the disposition options in “Results” of the “Problem Data Collection Sheet (PDCS)” template.
The adequacy of your firm’s response letter dated 1/03/2024 and response update dated 2/15/2024, cannot be determined at this time. The response notes that your firm has taken corrective actions to address the deficiencies with the nonconforming product procedures. These include revision of procedures and the training of personnel. Your firm has opened a CAPA to ensure activities are captured within the CAPA subsystem and to determine if any additional action(s) are needed. However, the response does not furnish specific information regarding the results or outcomes of these corrective actions as many remain ongoing.
4. Failure to adequately establish procedures for design change, as required by 21 CFR 820.30(i). Your firm’s procedure “Design Change,” GLB-QS-PCD-0053, Revision 13.1, Dated 14 Oct 2022, has not been adequately established to ensure design changes are validated or where appropriate verified, reviewed and approved before their implementation. For example, your firm completed Design Change Plan “DxI 9000
(b)(4)
DCP,” MDF2023-3479, Revision 1.1, Dated 26 Apr 023. No design inputs were identified as impacted in this design change, as section
(b)(4)
of the form was not completed as this change was considered a
(b)(4)
design change. A verification was completed under “
(b)(4)
Verification by Analysis and Inspection Report,” Revision 2.2, Dated 26 Apr 2023. In section 3, this verification identifies
(b)(4)
requirements the
(b)(4)
must meet, stating it “…must also mitigate the failure mode identified above by meeting these design considerations.” These are not requirements listed in current design input documentation, nor were these requirements added to the design input documentation, during or after the design change.
The adequacy of your firm’s response letter dated 1/03/2024 and response update dated 2/15/2024, cannot be determined at this time. The response notes that your firm is in the process or has implemented corrective actions to address the deficiencies with the Design Change procedures. These include revisions to procedures conducting a retrospective review of design changes identified as
(b)(4)
, and the training of personnel. Your firm has opened a CAPA to determine if any additional action(s) are needed and whether corrective actions are effective. In reviewing your firm’s updated procedures, they do not ensure that
(b)(4)
Design Changes are validated (or where appropriate verified) prior to implementation of the change. Adequacy of the response cannot be determined as the response does not furnish specific information regarding the results or outcomes of these corrective actions as many remain ongoing.
Your firm should take prompt action to address any violations identified in this letter. Failure to adequately address this matter may result in regulatory action being initiated by the FDA without further notice. These actions include, but are not limited to, seizure, injunction, and civil money penalties.
Other federal agencies may take your compliance with the FD&C Act and its implementing regulations into account when considering the award of federal contracts. Additionally, should FDA determine that you have Quality System regulation violations that are reasonably related to premarket approval applications for Class III devices, such devices will not be approved until the violations have been addressed. Should FDA determine that your devices or facilities do not meet the requirements of the Act, requests for Certificates to Foreign Governments (CFG) may not be granted.
Please notify this office in writing within fifteen business days from the date you receive this letter of the specific steps your firm has taken to address the noted violations, as well as an explanation of how your firm plans to prevent these violations, or similar violations, from occurring again. Include documentation of the corrections and/or corrective actions (which must address systemic problems) that your firm has taken. If your firm’s planned corrections and/or corrective actions will occur over time, please include a timetable for implementation of those activities. If corrections and/or corrective actions cannot be completed within fifteen business days, state the reason for the delay and the time within which these activities will be completed. Your firm’s response should be comprehensive and address any violations included in this Warning Letter.
If you believe that your products are not in violation of the FD&C Act, include your reasoning and any supporting information for our consideration as part of your response.
Your firm’s response should be sent to: Melissa Michurski, Director of Compliance Branch, at oradevices2firmresponse@fda.hhs.gov. Refer to CMS # 678042 when replying. If you have any questions about the contents of this letter, please contact: Compliance Officer, Rafael Padilla at 312-596-4212 or Rafael.padilla@fda.hhs.gov.
Finally, you should know that this letter is not intended to be an all-inclusive list of the violations at your firm’s facility. It is your firm’s responsibility to ensure compliance with applicable laws and regulations administered by FDA. The specific violations noted in this letter and in the Inspectional Observations, FDA 483, issued at the close of the inspection may be symptomatic of serious problems in your firm’s manufacturing and quality management systems. Your firm should investigate and determine the causes of any violations and take prompt actions to address any violations and bring the products into compliance.
Sincerely yours,
/S/
Blake Bevill
Program Division Director
Office of Medial Device and Radiological Health Operations
(OMDRHO), Division 2 Central
Content current as of:
04/02/2024
Regulated Product(s)
Medical Devices