BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    VARIAN MEDICAL SYSTEM

    MDR report key: 2268920 · Received September 22, 2011

    Report

    Report Number
    MW5022376
    Event Type
    Malfunction
    Date Received
    September 22, 2011
    Date of Event
    June 7, 2011
    Report Date
    September 22, 2011
    Manufacturer
    VARIAN MEDICAL SYSTEMS
    Product Code
    IYE
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    OH, US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Description of Event or Problem · 1

    TWO PTS WERE SCHEDULED (BACK TO BACK) FOR RADIATION THERAPY FOR PROSTATE CANCER. FOR PT CONVENIENCE, THEY SWITCHED THEIR ORDER FOR TREATMENT. (B)(6) WAS TAKEN BACK TO THE TREATMENT AREA TO CHANGE CLOTHES AND THEN ENTERED THE TREATMENT ROOM. HIS NAME WAS BELOW THE OTHER PT ON THE SCREEN BUT THE TECH HIGHLIGHTED HIS NAME AND HIS PHOTO APPEARED. THE TECH USED THE MOUSE TO MOVE DOWN ON THE SCREEN TO THE "TREAT" BOX AND HE CLICKED ON THE "TREAT" BOX AND THE TREATMENT COMMENCED. THIS TOOK LESS THAN 1 SECOND. AT THE END OF THE TREATMENT, THE TECH NOTICED THAT THE NAME AND PICTURE ON THE SCREEN WERE OF THE FIRST PT WHO WAS SCHEDULED FOR RADIATION THERAPY, NOT THE PT WHO JUST COMPLETED THE TREATMENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 VARIAN MEDICAL SYSTEM LINEAR ACCELERATOR IYE VARIAN MEDICAL SYSTEMS

    Patients

    Seq Age Sex Outcome Treatment
    1