07

May

2020

Recall – Treatment planning system dose discrepancy

recall, softwareerror

0

Company: Viewray, Inc.
Date of Enforcement Report: 5/7/2020
Class II

PRODUCT

ViewRay System: Model No. 10000 and 20000 for radiation treatment. PN11440 MRIdian System Treatment Planning and Delivery System (TPDS) software

Recall Number: Z-1803-2020

REASON

Registering dose and structures in the treatment delivery workflow could result in an alignment discrepancy between the imported previously delivered dose and the displayed patient anatomy and structures. The MRIdian TPDS software shows this misalignment to the user in the predicted dose-volume histogram (DVH). The misalignment impact may not be obvious to the user. During plan re-optimization the previously delivered dose would be incorrectly accounted for by the software. This may result in unexpectedly higher or lower dose than the intended dose calculated for the subsequent treatment plan. When this occurs in the treatment planning workflow, the registration fails to align the dose with the image and the user is unable to proceed.

RECALLING FIRM/MANUFACTURER

Viewray, Inc. on 11/18/2019. Voluntary: Firm Initiated recall is ongoing.

VOLUME OF PRODUCT IN COMMERCE

32

DISTRIBUTION

U.S. Nationwide and International

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