BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    MRIDIAN LINAC SYSTEM

    MDR report key: 16311656 · Received February 7, 2023

    Report

    Report Number
    3011233554-2023-00001
    Event Type
    Malfunction
    Date Received
    February 7, 2023
    Date of Event
    January 19, 2023
    Report Date
    February 6, 2023
    Manufacturer
    VIEWRAY, INCORPORATED
    Product Code
    IYE
    UDI-DI
    10868029000305
    PMA / PMN Number
    K212958
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FL, US
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    THE ROOT CAUSE OF THE EVENT WAS IDENTIFIED AS THE MRIDIAN LINAC OPERATOR'S MANUAL (L-0240) CONTAINS INSTRUCTIONS REGARDING HOW TO DISABLE FRACTIONS WHICH IS INCONSISTENT WITH THE SOFTWARE'S IMPLEMENTATION. THE INSTRUCTIONS WERE CARRIED OVER FROM V2.0 SOFTWARE VERSION IN ERROR, THE MANUAL SHOULD DESCRIBE THE A3I AND 3.0 WORKFLOW RATHER THAN THE V2.0 PROCESS. THE INVESTIGATION INTO THIS ISSUE IS AS FOLLOWS: 1. FOR THE A3I AND V3.0 SOFTWARE, WHEN A FRACTION IS LOCKED ON THE TPS THE FRACTION "APPEARS" TO BE LOCKED AS PER THE L-0240 REV. B "OPERATOR'S MANUAL FOR THE MRIDIAN A3I SYSTEM VERSION 5.5. 2. WHEN OPENING THE SAME PATIENT'S FRACTION CALENDAR ON THE TDS, THOUGH, THE FRACTION DOES NOT APPEAR LOCKED AS DESCRIBED IN THE L-0240 REV. B "OPERATOR'S MANUAL FOR THE MRIDIAN A3I SYSTEM VERSION 5.5. 3. A REVIEW OF L-0240 REV. B "OPERATOR'S MANUAL FOR THE MRIDIAN A3I SYSTEM VERSION 5.5" HAS BEEN PERFORMED FOR THE FRACTION LOCK FUNCTIONALITY. FOR THE FRACTION LOCKING FUNCTION L-0240 REV. B SAYS "YOU CAN LOCK FRACTIONS SO THEY CANNOT BE DELIVERED UNLESS UNLOCKED BY AN AUTHORIZED USER". THERE IS NO MENTION AS TO THE FRACTION LOCKING FUNCTION WORKING ON THE TPS BUT NOT THE TDS. 4. THE COMPLAINT DESCRIBES A POTENTIAL ISSUE THAT WAS AVOIDED DUE TO THE EXISTING MITIGATIONS IN THE SYSTEM. NO PATIENT WAS MISTREATED, NO HARM OCCURRED, AND NO LOCKED FRACTIONS WERE DELIVERED BECAUSE THE MITIGATIONS FOR PLAN SELECTION AND APPROVAL DID AS THEY WERE DESIGNED. 5. WHEN THE PHYSICIAN ADAPTS AND CREATES A REPLACEMENT PLAN AFTER STARTING THE FIRST PLAN, THERE IS NO REQUIREMENT TO LOCK THE REMAINING FRACTIONS OF THE FIRST PLAN. THERE ARE MULTIPLE WAYS TO DEAL WITH THIS SITUATION, AND LOCKING THE REMAINING FRACTIONS IS JUST ONE POTENTIAL METHOD. NONE OF THE METHODS ARE REQUIRED TO BE USED. THE HOSPITAL WORKFLOW DETERMINES HOW THE SITUATION IS MANAGED IN THE SYSTEM.

    Description of Event or Problem · 0

    A USER OF VIEWRAY'S MRIDIAN LINAC SYSTEM REPORTED AN ISSUE WITH THE A3I DELIVERY CALENDAR. THE SITE REVISED A PATIENT'S PLAN AFTER TWO (2) FRACTIONS. THE REVISED PLAN WAS PLACED INTO A NEW DELIVERY CALENDAR. THE REMAINING FRACTIONS OF THE ORIGINAL DELIVERY CALENDAR WERE LOCKED ON THE TREATMENT PLANNING SYSTEM (TPS) AS PER THE MRIDIAN LINAC OPERATOR'S MANUAL (L-0240), BUT WHEN THE THERAPIST WENT TO TREAT THE PATIENT THEY NOTICED THAT THE LOCKED FRACTIONS WITHIN THE ORIGINAL PLAN WERE STILL AVAILABLE FOR DELIVERY. THE SITE INDICATED THAT THIS IS DIFFERENT BEHAVIOR AS COMPARED TO THE WAY THE DELIVERY CALENDAR USED TO PERFORM IN THE V2 SOFTWARE VERSION. WITH THE A3I SOFTWARE, THE SITE WAS UNCLEAR PER THE MRIDIAN LINAC OPERATOR'S MANUAL (L-0240) HOW TO DEACTIVATE UNUSED FRACTIONS IN THE PARTIALLY DELIVERED DELIVERY CALENDAR AND ALSO HOW TO DEACTIVATE SOME FRACTIONS ON THE NEW DELIVERY CALENDAR.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    81365 MRIDIAN LINAC SYSTEM MEDICAL CHARGED-PARTICLE RADIATION THERAPY SYSTEM IYE VIEWRAY, INCORPORATED 20000-01 10868029000305

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown Other