Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-2537-2018Class II

Patient Positioning System with KRC2 controller using software versions 2.3.1 2.3.10

Forte Automation Systems, Inc. / initiated 2017-09-05 / Terminated / root cause: software

Forte Automation Systems Inc began a recall of Patient Positioning System with KRC2 controller using software versions 2.3.1 2.3.10 Product Usage: The patient positioning system is a SCARA designed robotic... on . FDA classified it as Class II and gives the reason as "Communications between the Patient Positioning System and the accuracy filter can periodically fail with no clear indication to the operator". As of , the recall status on record is Terminated, and MDM tags the root cause as software.

Recall record

Recall number
Z-2537-2018
Classification
Class II
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
Forte Automation Systems, Inc.
Product
Patient Positioning System with KRC2 controller using software versions 2.3.1 2.3.10 Product Usage: The patient positioning system is a SCARA designed robotic arm designed to position a patient for medical procedures prescribed by oncologists and others that require a high degree of accuracy and repeatability.
Product code
JAI Couch, Radiation Therapy, Powered
Reason for recall
Communications between the Patient Positioning System and the accuracy filter can periodically fail with no clear indication to the operator.
Root cause tag
software
FDA root cause
Software design
Action
On September 5, 2017 Forte has distributed an Urgent Medical Device Correction letter with the following information, Subject: Robotic Treatment Table Positioning Error Commercial Name of Affected Product: Patient Positioning System Affected Version(s) / Lot(s): KRC2 Controllers with software version 2.3.1 2.3.10 Reference / FSCA Identifier: 3003900998-2017-00001 Type of Action: Notification and Correction This letter provides users with a Description of the Problem, Details, Recommended User Action and Forte Automation Systems, Inc. Actions. This document also Pending resolution with a permanent solution, Forte Automation Systems, Inc. recommends reimaging the patient prior to treatment, especially after any table movement. This includes movement initiated by the image position verification system. It also advises users that a solution for the issue is in development.
Quantity in commerce
13
Distribution
US in the state of California
Product codes and lots
PPS Serial Number Cabinet Type Software Version  7757-11 KRC2 2.3.3  7757-21 KRC2 2.3.3  7757-31 KRC2 2.3.3  7757-41 KRC2 2.3.3  7757-51 KRC2 2.3.8  7755-21 KRC2 2.3.3  7755-31 KRC2 2.3.3  7755-41 KRC2 2.3.3  7392-2 KRC2 2.3.3  7392-3 KRC2 2.3.3  7392-4 KRC2 2.3.3  7392-1 KRC2 2.3.8  7392-5 KRC2 2.3.8

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-2537-2018
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-2537-2018Class IITerminatedVoluntary: Firm initiated