Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-0821-2015Class II

VERO Linear Accelerator System, Model Number MHI-TM2000, MHI Identifier M101-14021, Software Version: 3.1...

Mitsubishi Heavy Industries, Ltd., Hiroshima Machinery Work / initiated 2014-12-02 / Terminated / root cause: software

MITSUBISHI HEAVY INDUSTRIES, LTD., HIROSHIMA MACHINERY WORK began a recall of VERO Linear Accelerator System, Model Number MHI-TM2000, MHI Identifier M101-14021, Software Version: 3.1, 3.2 and 3.5.0 on . FDA classified it as Class II and gives the reason as "Software Anomaly. The VERO MHI-TM2000 Operator Console may provide Patient Positioning System (ExacTrac) with Image Angle Information Used for the 1st Port Image, for a subsequent port image fusion. As the result...". As of , the recall status on record is Terminated, and MDM tags the root cause as software.

Recall record

Recall number
Z-0821-2015
Classification
Class II
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
Mitsubishi Heavy Industries, Ltd., Hiroshima Machinery Work
Product
VERO Linear Accelerator System, Model Number MHI-TM2000, MHI Identifier M101-14021, Software Version: 3.1, 3.2 and 3.5.0.
Product code
IYE Accelerator, Linear, Medical
Reason for recall
Software Anomaly. The VERO MHI-TM2000 Operator Console may provide Patient Positioning System (ExacTrac) with Image Angle Information Used for the 1st Port Image, for a subsequent port image fusion. As the result, ExacTrac may display a Digitally Reconstructed Radiograph (DRR) image taken from the angle for the 1st port image fusion, rather than the one taken from the angle for the intended port
Root cause tag
software
FDA root cause
Software design
Action
Mitsubishi sent a Field Safety Notice dated November 14, 2014, that was e-mailed to US end users on December 2, 2014, which provided actions to be taken by the end users. If users need any further information or support concerning this issue, they may contact MHI's Customer Service Representative, Brainlab AG in Germany, contact person: Franz Gum, Tel: +49-89-99-1568-0, Fax: +49-89-99-1568-33, E-mail: [email protected]. If any other abnormality is detected, stop operation and contact MHI's Customer Service representative immediately. --- An Updated Field Safety Notice (dated December 4, 2014,) was sent to end users to correct some terms used in the initial notification.
Quantity in commerce
Domestic: 4 units
Distribution
US Distribution to the states of NY, FL, TX and OH.
Product codes and lots
Serial Numbers: 201902, 203901, 203919, and 203924 (US only)

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-0821-2015
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-0821-2015Class IITerminatedVoluntary: Firm initiated