Events

Retiro De Equipo (Recall) de Monaco with software versions 3.1 and higher (Radiation therapy treatment planning system)

Según Department of Health, Therapeutic Goods Administration, este evento ( retiro de equipo (recall) ) involucró a un dispositivo médico en Australia que fue producido por Elekta Pty Ltd.

¿Qué es esto?

Una corrección al equipo o acción de retiro tomada por el fabricante para abordar un problema con un dispositivo médico. Los retiros (recalls) ocurren cuando un dispositivo médico está defectuoso, cuando puede poner en riesgo la salud, o cuando simultáneamente está defectuoso y puede poner en riesgo la salud.

Más información acerca de la data acá
  • Tipo de evento
    Recall
  • ID del evento
    RC-2016-RN-01091-1
  • Clase de Riesgo del Evento
    Class II
  • Fecha de inicio del evento
    2016-08-19
  • País del evento
    Australia
  • Fuente del evento
    DHTGA
  • URL de la fuente del evento
    https://apps.tga.gov.au/Prod/sara/arn-detail.aspx?k=RC-2016-RN-01091-1
  • Notas / Alertas
    Australian data is current through July 2018. All of the data comes from the Australian Therapeutic Goods Administration, except for the categories Manufacturer Parent Company and Product Classification.
    The Parent Company and the Product Classification were added by ICIJ.
    The parent company information is based on 2017 public records. The device classification information comes from FDA’s Product Classification by Review Panel, based on matches of recall data from the U.S. and Australia.
  • Notas adicionales en la data
  • Causa
    In a specific workflow where contours are edited and then the contour is deleted on some slices and saved in the same session, it is possible that the deleted contours are still present which would not be the intent of the planner. if the patient is not saved and recalled, in a subsequently created plan the bev will show the contours as still present while the transverse, sagittal and coronal views will show the contours as deleted. the total volume of the structure reported in the dvh and the structure control will not match. if the study set is saved and reopened before plan creation the total volume of the structure reported in the dvh and the structure control will be corrected. a similar workflow could trigger the defect if contour deletions and edits are performed while a plan is loaded. if the user bases their clinical decisions on incorrect contours it could lead to dose errors and potential patient mistreatment. there have been no reports of injuries due with this issue.
  • Acción
    Elekta is advising users to incorporate the one of the following steps into the general contouring workflow: 1. Delete before edit: For newly generated contours, delete any unwanted contours and save before making edits (move, rotate, reshape) 2. If further deletions are required after edits are performed, save and unload the data. Then reload the data before deleting. This will allow the affected code to locate all the coordinate points of the contour. 3. Delete Contour and start over. 4. Clear Contour and start over. Elekta will be implementing a software upgrade as a permanent correction.

Device

Monaco with software versions 3.1 and higher (Radiation therapy treatment planning system)
  • Modelo / Serial
    Monaco with software versions 3.1 and higher (Radiation therapy treatment planning system)ARTG Number: 215960
  • Manufacturer
    Elekta Pty Ltd

Manufacturer

Elekta Pty Ltd
  • Empresa matriz del fabricante (2017)
    Elekta AB
  • Source
    DHTGA