Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-0676-2020Class II

MRIdian Linac Radiation Therapy System Model 10000 and 20000

Viewray, Inc. / initiated 2019-03-03 / Terminated / root cause: labeling and UDI

Viewray, Inc. began a recall of MRIdian Linac Radiation Therapy System Model 10000 and 20000 on . FDA classified it as Class II and gives the reason as "Issue with transferring treatment regiment from one system to another. Adequate instructions for transferring treatment plan(s) are not provided within the operator's manual or within the software operating system". As of , the recall status on record is Terminated, and MDM tags the root cause as labeling and UDI.

Recall record

Recall number
Z-0676-2020
Classification
Class II
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
Viewray, Inc.
Product
MRIdian Linac Radiation Therapy System Model 10000 and 20000
Product code
IYE Accelerator, Linear, Medical
Reason for recall
Issue with transferring treatment regiment from one system to another. Adequate instructions for transferring treatment plan(s) are not provided within the operator's manual or within the software operating system.
Root cause tag
labeling and UDI
FDA root cause
Error in labeling
Action
On 03/03/2019, the firm emailed an "URGENT DEVICE RECALL" to customers to inform them of a safety issue with the Treatment Planning and Delivery System (TPDS) in the MRIdian System. The notice explained that when a partially-completed patient treatment regiment is moved to their system from another system, the use needs to rescale the plan. The TPDS does not automatically rescale the treatment plan. The customers are instructed: If they want to move a treatment plan from one system to another and still show the total original prescribed dose on the MRIdian TPDS the customer will have multiple ways to do this. 1. Once the user/operator has evaluated the plan at the full dose, ensure the prescription matches the dose and number of fractions to be delivered on the MRIdian, and scale the dose to the target by either renormalizing or changing the target objective in the optimizer. 2. Keep the original total number of fractions (including those delivered elsewhere) in the prescription but when the plan is assigned to the fractions in the delivery calendar, Discontinue the number of fractions that have already been delivered on another system. 3. Import the previously delivered dose files as a RTDose and fuse with the plan images. Optimize to the remaining target dose that is to be deliver on MRIdian. Include the imported dose as Previously Delivered Dose and Calculate in the Finish screen to display the full dose which has and will be delivered. Ensure the prescription matches the dose and number of fractions to be delivered on the MRIdian. 4. Import the previously delivered dose files as RTDose and fuse with the plan images. Optimize to the original total dose, including the Previously Delivered Dose as part of the optimization. Ensure the prescription matches the total dose and number of fractions including those treated elsewhere and those to be delivered on the MRIdian. The customer is also informed that the Recalling Firm will address this is
Quantity in commerce
24 Systems
Distribution
US - CA, FL, IL, MI, MO, NY, and WI OUS: Denmark, France, Germany, Italy, Japan, Netherlands, Turkey, South Korea, and UAE
Product codes and lots
Serial Numbers: 100, 101, 102, 103, 104, 105, 107, 108, 112, 113, 201, 202, 203, 204, 205, 206, 209, 211, 213, 214, 217, 221, 223, 225  Device Listing Number: D158423 and D297999

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-0676-2020
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-0676-2020Class IITerminatedVoluntary: Firm initiated