Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-1944-2012Class II

MOSAIQ Oncology Information Systems interfaced to Elekta Treatment machines. An image enabled electronic...

Elekta Limited / initiated 2012-06-08 / Terminated / root cause: software

Impac Medical Systems Inc began a recall of MOSAIQ Oncology Information Systems interfaced to Elekta Treatment machines. An image enabled electronic medical record system used for oncology workflow... on . FDA classified it as Class II and gives the reason as "Impac Medical became aware of a problem with the recording of the Wedge Motor Units in MOSAIQ when it resumes after a machine terminates/faults, the remaining Wedge MU was being erroneously set to zero". As of , the recall status on record is Terminated, and MDM tags the root cause as software.

Recall record

Recall number
Z-1944-2012
Classification
Class II
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
Elekta Limited
Product
MOSAIQ Oncology Information Systems interfaced to Elekta Treatment machines. An image enabled electronic medical record system used for oncology workflow management. Manufactured by: Impac Medical Systems 100 Mathilda Place, 5th floor Sunnyvale, Ca 94086
Product code
IYE Accelerator, Linear, Medical
Reason for recall
Impac Medical became aware of a problem with the recording of the Wedge Motor Units in MOSAIQ when it resumes after a machine terminates/faults, the remaining Wedge MU was being erroneously set to zero.
Root cause tag
software
FDA root cause
Software design
Action
A User Notice began being distributed on June 8, 2012. This will be followed by contact at each site by IMPAC support to determine if the site is affected by this issue, and if so, the upgraded version will be suggested. The Notice identified the affected device, the problem, the clinical impact, along with the interim mitigations and the final resolution. Users are encouraged to monitor daily delivery and recordings of treatments to be sure that the Wedge Motor Units treatments are properly delivered. The letter also recommends that treatment charts be checked weekly and that users not override any parameters in MOSAIQ until the machine setup has been completed. Users are to contact Elekta Support for the upgrade.
Quantity in commerce
11 affected sites
Distribution
Worldwide Distribution -- USA, including the states of VA, CT, GA, NJ and NY and the countries of Belgium, Denmark, France, and the United Kingdom.
Product codes and lots
Version 2.10 - all builds and version 2.20 - builds up to and including 2.20.07A7.

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-1944-2012
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-1944-2012Class IITerminatedVoluntary: Firm initiated