Rappel de RayStation 6 (RayPlan 2) and RayStation 7 (RayPlan 7) when used with photon Collapsed Cone dose calculation

Selon Department of Health, Therapeutic Goods Administration, ce/cet/cette rappel concerne un dispositif en/au/aux/à Australia qui a été fabriqué par Emergo Asia Pacific Pty Ltd T/a Emergo Australia.

Qu'est-ce que c'est?

Une correction ou un retrait opéré par un fabricant afin de répondre à un problème causé par un dispositif médical. Les rappels surviennent lorsqu'un dispositif médical est défectueux, lorsqu'il pourrait poser un risque pour la santé, ou les deux à la fois.

En savoir plus sur les données ici
  • Type d'événement
    Recall
  • ID de l'événement
    RC-2018-RN-00333-1
  • Classe de risque de l'événement
    Class II
  • Date de mise en oeuvre de l'événement
    2018-05-16
  • Pays de l'événement
  • Source de l'événement
    DHTGA
  • URL de la source de l'événement
  • Notes / Alertes
    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.
  • Notes supplémentaires dans les données
  • Cause
    The field measure calculation may be incorrect for certain linac types. the error can affect beam commissioning of machines with the mlc closer to the source than both x- and y-jaws (e.G., elekta synergy with mlci/mlci2). the error can also affect the dose calculation in treatment planning with the same type of machines as well as machines with fixed jaws (e.G., elekta bm and vero), for some specific types of treatment plans.If the elekta synergy with mlci/mlci2, or a linac with similar collimator setup, is commissioned with measurement conditions ‘mlc only’, it may lead to errors in the output factor corrections (ofcs) and dose normalisation of the beam model. this is expected to result in a systematic error of 0 to 2% for most treatment plans and typical variations in the beam model ofcs.To date, there have been no reports of injury as a result of this issue.
  • Action
    Emergo is advising users: 1. Do not use ‘MLC only collimated’ to set output factor corrections (OFCs) in beam modelling of Elekta Synergy machines with MLCi/MLCi2 or any other machine with the MLC closer to the source than both the x- and y-jaws. Always use ´Jaws and MLC collimated´.; and 2. Be aware that there is an error in the field measure calculation for machines with the MLC closer to the source than both the x- and y-jaws, and for machines with fixed jaws. Make sure to perform patient-specific QA before treatment delivery for treatment plans with fields where: 1) closed MLC leaves are positioned inside the jaw field and 2) the minimum static/dynamic tip gap is larger than 0.001 cm. This issue will be resolved in the next version of RayStation/RayPlan, scheduled for market release in June 2018.

Device

  • Modèle / numéro de série
    RayStation 6 (RayPlan 2) and RayStation 7 (RayPlan 7)when used with photon Collapsed Cone dose calculationBuild Number: 6.0.0.24, 6.1.0.26, 6.1.1.2, 6.2.0.7, or 7.0.0.19ARTG Number: 195288(Emergo Asia Pacific T/a Emergo Australia - Radiation therapy treatment planning system)
  • Manufacturer

Manufacturer