Events

Recall of Monaco software versions 5.10.00 and higher

According to Department of Health, Therapeutic Goods Administration, this recall involved a device in Australia that was produced by Elekta Pty Ltd.

What is this?

A correction or removal action taken by a manufacturer to address a problem with a medical device. Recalls occur when a medical device is defective, when it could be a risk to health, or when it is both defective and a risk to health.

Learn more about the data here
  • Type of Event
    Recall
  • Event ID
    RC-2016-RN-00651-1
  • Event Risk Class
    Class I
  • Event Initiated Date
    2016-05-25
  • Event Country
    Australia
  • Event Source
    DHTGA
  • Event Source URL
    https://apps.tga.gov.au/Prod/sara/arn-detail.aspx?k=RC-2016-RN-00651-1
  • Notes / Alerts
    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.
  • Extra notes in the data
  • Reason
    When dicom is exporting a 3d monaco plan and the “composite field sequencing” (cfs) checkbox is selected, the y jaws will snap to the port shape when they should remain where they were defined. this occurs when the port shape used to define or edit the mlc positions extends beyond or inside the actual jaw positions. the defect is triggered when using a workflow for forward planning imrt that involves creating multiple beams for the same gantry angle with a single mlc shape defined for each beam. these beams are then exported using cfs to combine the individual 3d beams into a single imrt beam sequence. the planned and approved dose distribution will not agree with the dose delivered. this deviation is considered as a geometric miss and the patient can be overdosed or under dosed depending on whether the mlc shape is drawn outside or inside of the collimator jaws. there is a remote probability that serious injury could occur.
  • Action
    Elekta is advising users to avoid using the CFS option for any 3D delivery mode plan, including Forward IMRT based plans. A software correction will be implemented as a permanent correction. This action has been closed-out on 09/05/2017.

Device

Monaco software versions 5.10.00 and higher

Manufacturer

Elekta Pty Ltd
  • Manufacturer Parent Company (2017)
    Elekta AB
  • Source
    DHTGA