FDA Adverse Event Malfunction Summary report: N

MEVATRON KDS-2

MDR report key: 1013982 · Received March 12, 2008

Report

Report Number
2910081-2008-00015
Event Type
Malfunction
Date Received
March 12, 2008
Date of Event
February 6, 2008
Report Date
February 6, 2008
Manufacturer
SIEMENS MEDICAL SOLUTIONS
Product Code
IYE
PMA / PMN Number
K862339
Removal / Correction Number
NA
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
GM
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 1

COMPLAINT INVESTIGATION IS STILL ON GOING.

Description of Event or Problem · 1

IN THE ABUNDANCE OF CAUTION, THIS ISSUE IS BEING REPORTED TO THE REGULATORY AGENCY. A PRODUCT ISSUE HAS BEEN REPORTED WITH OUR MEDICAL LINEAR ACCELERATOR'S LEAD COUNTERWEIGHTS. THE LEAD COUNTERWEIGHTS (APPROXIMATELY 30-40KG) THAT WERE ATTACHED TO THE GANTRY STRUCTURE OPPOSITE FROM THE COLLIMATOR (BEAM LIMITING DEVICE) HAD COME LOOSE FROM ITS MOUNTING SCREWS. INVESTIGATION BY A SERVICE ENGINEER FOUND THAT THE MOUNTING SCREWS HAD SHEARED OFF. NO INJURY HAS BEEN REPORTED AS THE SURROUNDING GANTRY COVER RETAINED THE LOOSE LEAD COUNTERWEIGHTS. HOWEVER, IF MALFUNCTION WERE TO RECUR DURING SERVICE INTERVENTION WITH GANTRY COVERS REMOVED, POTENTIAL FOR SERIOUS INJURY IS POSSIBLE.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 MEVATRON KDS-2 ACCELERATOR, LINEAR, MEDICAL IYE SIEMENS MEDICAL SOLUTIONS NA

Patients

Seq Age Sex Outcome Treatment
1