BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    LEKSELL GAMMA KNIFE

    MDR report key: 1054240 · Received May 29, 2008

    Report

    Report Number
    9612186-2008-00008
    Event Type
    Malfunction
    Date Received
    May 29, 2008
    Date of Event
    April 28, 2008
    Report Date
    May 28, 2008
    Manufacturer
    ELEKTA INSTRUMENT AB
    Product Code
    IWB
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    BE
    Reporter Occupation
    PHYSICIST

    Narratives

    Additional Manufacturer Narrative · 1

    INVESTIGATION RESULTS: ACTUATOR MFR MADE UNAUTHORIZED COMPONENT MATERIAL CHANGE RESULTING IN COMPONENT FAILURE DURING USE. COMPONENT MATERIAL HAS BEEN CORRECTED BY SUBCONTRACTOR AND NEW COMPONENT REPLACEMENT INITIATED (SEE BELOW). CORRECTIVE ACTION: TECHNICAL NOTE 200 068, "SAFETY ISSUE WITH HELMET HOIST ACTUATOR" AND FIELD CHANGE ORDER 200 067, "INVESTIGATION AND CORRECTION OF HELMET CHANGER ACTUATORS" WERE BOTH RELEASED AS CORRECTIVE ACTIONS TO ADDRESS THIS ISSUE IN 2008. TECHNICAL NOTE 200 068 SERVES AS A CAUTION TO USERS OF THE GAMMA KNIFE UNTIL SUCH TIME AS THE PERMANENT FIX CAN BE INSTALLED. FIELD CHANGE ORDER 200 067 IS THE PERMANENT FIX ISSUED, AND INCLUDES SPECIFIC SERIAL NUMBERS OF MACHINES THAT WERE AFFECTED. AT THIS PARTICULAR SITE, A NEW ACTUATOR WAS INSTALLED AS PART OF THE CORRECTIVE ACTION ASSOCIATED WITH FIELD CHANGE ORDER 200 067. INSTALLATION OF THE NEW ACTUATOR SUCCESSFULLY ADDRESSED THE PROBLEMS SEEN EARLIER.

    Description of Event or Problem · 1

    THE ACTUATOR SUPPLIED WITH FIELD CHANGE ORDER 0000748, PART NUMBER 1005050, WAS INSTALLED IN 2008. DURING THE HELMET CHANGE PHASE OF TREATMENT, THE NUT IN THE LINER ACTUATOR UNSCREWED AND LET THE HELMET DROP.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 LEKSELL GAMMA KNIFE SYSTEM, RADIATION THERAPY, RADIONUCLIDE IWB ELEKTA INSTRUMENT AB

    Patients

    Seq Age Sex Outcome Treatment
    1