Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-2350-2020Class II

RayStation 9B, UDI # 07350002010266 -

RaySearch Laboratories AB (publ) / initiated 2020-05-18 / Terminated / root cause: software

RAYSEARCH LABORATORIES AB began a recall of RayStation 9B, UDI # 07350002010266 - Product Usage: For radiation therapy and medical oncology which can also be used to administer treatments on . FDA classified it as Class II and gives the reason as "Software error was identified in the Pencil Beam Scanning (PBS) and Line Scanning (LS) dose calculation algorithms that could result in a local underestimation of expected dose". As of , the recall status on record is Terminated, and MDM tags the root cause as software.

Recall record

Recall number
Z-2350-2020
Classification
Class II
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
RaySearch Laboratories AB (publ)
Product
RayStation 9B, UDI # 07350002010266 - Product Usage: For radiation therapy and medical oncology which can also be used to administer treatments.
Product code
MUJ System, Planning, Radiation Therapy Treatment
Reason for recall
Software error was identified in the Pencil Beam Scanning (PBS) and Line Scanning (LS) dose calculation algorithms that could result in a local underestimation of expected dose.
Root cause tag
software
FDA root cause
Software design
Action
On May 18, 2020, RaySearch Laboratories emailed an Urgent Field Safety Notice, Medical Device Correction #60564 letter to their customers. The letter listed the following actions to be taken by the users: always use the MC dose engine for final dose calculation, in robustness analysis, and dose tracking if possible (the MC dose engine is available in versions RayStation 6.0 and later); if the pencil beam dose engine is used for final dose calculation, ensure that all spots intersect the External ROI as seen in the Beams Eye View (BEV) of the Plan optimization module; if they do not, expand the External ROI so that all spots do intersect the External ROI, and re-optimize the plan if necessary; if the MC dose engine is used for final dose calculation, and hot spots related to tangential fields are observed, expand the External ROI so that the central axis of all spots intersect the External ROI and re-optimize the plan; educate planning staff and all users about this workaround; inspect your product and identify all installed units with the above software version number(s). RaySearch Laboratories asked all customers to confirm that they have read and understood the notice by replying to the notification email.
Distribution
US Nationwide distribution including in the states of Florida, Georgia, Utah, Virginia, California, Maryland, Arizona, Texas, Washington DC, Missouri, Massachusetts, Illinois, Oklahoma, New Jersey, Tennessee, and Louisiana.
Product codes and lots
UDI # 07350002010266  Build number: 9.1.0.933

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-2350-2020
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-2339-2020Class IITerminatedVoluntary: Firm initiated
Z-2340-2020Class IITerminatedVoluntary: Firm initiated
Z-2341-2020Class IITerminatedVoluntary: Firm initiated
Z-2342-2020Class IITerminatedVoluntary: Firm initiated
Z-2343-2020Class IITerminatedVoluntary: Firm initiated
Z-2344-2020Class IITerminatedVoluntary: Firm initiated
Z-2345-2020Class IITerminatedVoluntary: Firm initiated
Z-2346-2020Class IITerminatedVoluntary: Firm initiated
Z-2347-2020Class IITerminatedVoluntary: Firm initiated
Z-2348-2020Class IITerminatedVoluntary: Firm initiated
Z-2349-2020Class IITerminatedVoluntary: Firm initiated
Z-2350-2020Class IITerminatedVoluntary: Firm initiated
Z-2351-2020Class IITerminatedVoluntary: Firm initiated
Z-2352-2020Class IITerminatedVoluntary: Firm initiated
Z-2353-2020Class IITerminatedVoluntary: Firm initiated