Rare erroneous results on the Siemens Dimension Vista® platform due to urine carryover: A warning to current users

In 2014, the West Bank Laboratory at the University of Minnesota, part of the non-profit Fairview Health Services system, went live with two Siemens Dimension Vista® 500 instruments. In the first few months after go-live, the lab began receiving reports of rare, erroneous results from clinicians. After further investigation it was noted that most of the errors being reported followed a consistent pattern with significantly elevated potassium, BUN and creatinine. After months of unsuccessful troubleshooting with Siemens, our lab and others within the Fairview Health Services system began hypothesizing that urine carryover was occurring due to the pattern of elevated analytes, and asked Siemens to investigate this hypothesis. In March 2016 Siemens confirmed a software defect which omits an aliquot probe rinse resulting in sample carryover in rare cases. Our objective is to alert current users of the Siemens Dimension Vista® instruments to this rare but alarming phenomenon, discuss the frequency and impact of the erroneous results at our institution, and detail recommended steps for users of Siemens Dimension Vista® instruments to help retrospectively determine whether they have experienced similar erroneous results.