Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-2439-2015Class II

PTW UNIDOS webline: 1) REF T10023, 2) REF T10022 and 3) REF T10023 Firmware version 2.05. Dosimeter for...

PTW-Freiburg / initiated 2015-05-27 / Terminated / root cause: software

PTW-Freiburg began a recall of PTW UNIDOS webline: 1) REF T10023, 2) REF T10022 and 3) REF T10023 Firmware version 2.05. Dosimeter for radiation therapy, diagnostic radiology and health... on . FDA classified it as Class II and gives the reason as "In some cases, especially with high dose-per-pulse-rates typical for particle (specifically proton) therapy, measuring errors can result. Individual measurement intervals can be lost that are not visible to the user...". As of , the recall status on record is Terminated, and MDM tags the root cause as software.

Recall record

Recall number
Z-2439-2015
Classification
Class II
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
PTW-Freiburg
Product
PTW UNIDOS webline: 1) REF T10023, 2) REF T10022 and 3) REF T10023 Firmware version 2.05. Dosimeter for radiation therapy, diagnostic radiology and health physics.
Product code
IYE Accelerator, Linear, Medical
Reason for recall
In some cases, especially with high dose-per-pulse-rates typical for particle (specifically proton) therapy, measuring errors can result. Individual measurement intervals can be lost that are not visible to the user when there is a high dose-per-pulse rate resulting in a too-low dose being displayed on the monitor. This could result in a radiation over-exposure.
Root cause tag
software
FDA root cause
Software design
Action
PTW issues Urgent Safety Notice due to an error with firmware version 2.05 of the UNIDOS webline in some cases, especially with the high dose-per-pulse-rates typical for particle therapy, measuring errors can result.
Quantity in commerce
242 firmwares
Distribution
Distributed in CA, MI, MA, NC, NJ, NY, PA, TN, TX, PA & WI.
Product codes and lots
serial numbers: **T10021: 000005, 000019, 000037, 000041, 000047, 000049, 000058, 000066, 000074, 000076, 000079, 000099, 000107, 000125, 000141, 000144, 000158, 000161, 000168, 000175, 000186, 000212, 000221, 000224, 000229, 000231, 000254, 000262, 000274, 000294, 000301, 000302, 000327, 000351, 000352, 000382, 000401, 000413, 000424, 000437, 000445, 000452, 000470, 000477, 000486, 000504, 000525, 000528, 000535, 000567, 000593, 000594, 000649, 000655, 000658, 000659, 000663, 000678, 000686, 000710, 000711, 000731, 000752, 000756, 000763, 000785, 000792, 000793, 000796, 000800, 000820, 000829, 000830, 000857, 000860, 000863, 000865 ,000871, 000874, 000890, 000892, 000946, **T10022: 000003, 000046, 000066, 000087, 000096, 000106, 000118, 000138, 000172, 000178, 000183, 000186, 000188, 000210, 000240, 000317, 000336, 000347, 000350, 000351, 000358, 000360, 000392, 000398, 000420, 000422, 000425, 000434 -000453, 000456-000469, 000474, ** T10023: 000022, 000028, 000051, 00102, 000196, 000213, 000226, 000250, 000255, 000257, 000259, 000261, 000263, 000271, 000280, 000294

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-2439-2015
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-2439-2015Class IITerminatedVoluntary: Firm initiated