Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-0681-2008

Seimens Mevatron KD-2 Medical Charged-Particle Radiation Therapy System; (Interlock #51 Jaw Field Position)...

Siemens Medical Solutions USA, Inc. / initiated 2007-08-07 / Terminated / root cause: design

Siemens Medical Solutions USA, Inc began a recall of Seimens Mevatron KD-2 Medical Charged-Particle Radiation Therapy System; (Interlock #51 Jaw Field Position) Model Number: 9822685, Siemens Medical Solutions... on . The reason FDA records is "Incorrect field size -- Products manufactured prior to 1999 may experience jaw field size errors during interlock resulting in potential mistreatment if a light field check is not performed. This problem is present in...". As of , the recall status on record is Terminated, and MDM tags the root cause as design.

Recall record

Recall number
Z-0681-2008
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
Siemens Medical Solutions USA, Inc.
Product
Seimens Mevatron KD-2 Medical Charged-Particle Radiation Therapy System; (Interlock #51 Jaw Field Position) Model Number: 9822685, Siemens Medical Solutions, Concord, CA 94520
Product code
IYE Accelerator, Linear, Medical
Reason for recall
Incorrect field size -- Products manufactured prior to 1999 may experience jaw field size errors during interlock resulting in potential mistreatment if a light field check is not performed. This problem is present in machines with serial numbers less than 3094, as they do not contain redundant sensors for jaw position.
Root cause tag
design
FDA root cause
Device Design
Action
The firm has sent consignees a Customer Safety Advisory Notice on August 7, 2007 informing them that a misplacement of the X and/or Y jaws can occur if interlock #51 Jaw Field Position is asserted and then cleared with the left-hand key rest. The firm recommends that if an interlock issue is encountered tha treatment of the patient be discontined until this issue is resolved.
Quantity in commerce
55 units
Distribution
Worldwide Distribution
Product codes and lots
Serial Numbers: 1938, 1944, 1987, 2082, 2088, 2154, 2173, 2175, 2228, 2246, 2315, 2348, 1894, 1948, 1953, 2043, 2074, 2099, 2131, 2202, 2224, 2282, 2319, 2376, 2405, 2431, 2436, 2437, 2413, 2414, 1633, 1772, 1874, 1901, 1928, 1941, 1985, 2014, 2065, 2076, 2111, 2115, 2123, 2127, 2135, 2145, 2179, 2213, 2216, 2218, 2273, 2297, 2329, 2345, 2383