Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-1685-2021Class II

Multitom RAX with software version VF10

Siemens Medical Solutions USA, Inc. / initiated 2021-04-20 / Terminated / root cause: software

Siemens Medical Solutions USA, Inc began a recall of Multitom RAX with software version VF10 on . FDA classified it as Class II and gives the reason as "Siemens identified two issues, In some cases, it is possible to perform an image acquisition although more than 20% of the beam does not hit the detector. This may only occur when an organ program for the wall mode...". As of , the recall status on record is Terminated, and MDM tags the root cause as software.

Recall record

Recall number
Z-1685-2021
Classification
Class II
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
Siemens Medical Solutions USA, Inc.
Product
Multitom RAX with software version VF10
Product code
OWB Interventional Fluoroscopic X-Ray System
Reason for recall
Siemens identified two issues, In some cases, it is possible to perform an image acquisition although more than 20% of the beam does not hit the detector. This may only occur when an organ program for the wall mode without top alignment is selected and the system is moved to the centred position. If afterwards the operator activates the top alignment, increases the collimation, and lifts the tube, the system allows examination even with the tube being misaligned to the detector position. Hence, it is possible to overshoot the detector by more than 20%. From a clinical point of view, it is highly unlikely for the operator to trigger the examination as the misalignment is visible due to the light field being out of range. AND In very rare cases it may occur that the calculated dose value exceeds the limit of 2 Gy. This may potentially occur only when an organ program for free exposure is selected, and the system uses incorrect (too small) source-to-image distance (SID) for calculating applied dose. Hence, the calculated dose is much higher than the actual applied dose causing the buzzer, which normally notifies the operator about the exceeded limit of 2 Gy, to get activated erroneously.
Root cause tag
software
FDA root cause
Software design
Action
Siemens Healthineers sent an Urgent Medical Device Correction letters dated March 20, 2021 to all affected customers. The letter identified the affected product, problem and actions to be taken. Siemens Healthineers will issue a software correction (VF11C) that will eliminate both issues. The software solution will be distributed remotely via Update Instructions XP006/21/P.
Quantity in commerce
26
Distribution
US Nationwide distribution
Product codes and lots
software version VF10 model# 10860700

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-1685-2021
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-1685-2021Class IITerminatedFDA Mandated