Events

Surface Applicator Set with Leipzig-style Cone(indicated for treatment of small skin tumours or other superficial disease (such as keloid formations) with HDR brachytherapy) 의 리콜

Department of Health, Therapeutic Goods Administration에 따르면, 해당 리콜 는 Australia 에서 Varian Medical Systems Australasia Pty Ltd 에 의해 제조된 제품과 관련되어 있습니다.

이것은 무엇인가요?

의료기기에 문제가 생겼을 경우 제조사가 이를 바로잡거나 시장에서 회수하는 조치를 말한다. 회수(Recall)는 의료기기에 결함이 있거나, 건강에 위협이 되거나, 또는 결함도 있고 건강에도 위협이 될 경우에 발생한다.

데이터에 대해 더 자세히 알아보기 여기
  • 사례 유형
    Recall
  • 사례 ID
    RC-2015-RN-00446-1
  • 사례 위험등급
    Class II
  • 사례 시작날짜
    2015-05-27
  • 사례 국가
    Australia
  • 사례 출처
    DHTGA
  • 사례 출처 URL
    https://apps.tga.gov.au/Prod/sara/arn-detail.aspx?k=RC-2015-RN-00446-1
  • 비고 / 경고
    Australian data is current through July 2018. All of the data comes from the Australian Therapeutic Goods Administration, except for the categories Manufacturer Parent Company and Product Classification.
    The Parent Company and the Product Classification were added by ICIJ.
    The parent company information is based on 2017 public records. The device classification information comes from FDA’s Product Classification by Review Panel, based on matches of recall data from the U.S. and Australia.
  • 데이터 추가 비고
  • 원인
    The dosimetry data provided in the leipzig-style surface applicator's ifu was derived by performing monte carlo simulations. subsequent simulations were performed to refine the data, but this refined data was not published in an ifu update. the most significant discrepancy is that the actual dose rate of the applicator is approximately 14% higher than the rate published within the ifu. use of the dose rate as provided by the ifu without independent confirmation of the dose could result in an administration of dose greater than intended. this failure mode is not easily recognised by the user.
  • 조치
    Users are recommended the following action: · Users should CEASE USE of the published dose rate in the Surface Applicator Set with Leipzig-style Cone, GM11010080 IFU: Dose Characterization GM11010080 2012-09-06 · Users may use the Acuros BV to calculate dose rates and dose distributions of the surface applicators. · Users may use Thermoluminescent Dosimeters (TLDs) to obtain dose rates & dose distributions of the surface applicators. · Users may measure the surface applicator dosimetry using methods recommended in the following publication: Fulkerson RK, Micka JA, DeWerd LA. Dosimetric characterization and output verification for conical brachytherapy surface applicators. Part II. High dose rate 192lr sources. Medical Physics. 2014;41(2):022104. doi: 10.1118/ 1.4862506. Varian is continuing its investigation and will update the IFU with corrected values as soon as possible. Varian will distribute updated Leipzig-style Surface Applicator's IFU to all affected users upon release. This action has been closed-out on 17/08/2016.

Device

Surface Applicator Set with Leipzig-style Cone(indicated for treatment of small skin tumours or o...
  • 모델명 / 제조번호(시리얼번호)
    Surface Applicator Set with Leipzig-style Cone(indicated for treatment of small skin tumours or other superficial disease (such as keloid formations) with HDR brachytherapy)IFU version: Dose Characterization GM11010080, 2012-09-06 ARTG Number: 126867
  • Manufacturer
    Varian Medical Systems Australasia Pty Ltd

Manufacturer

Varian Medical Systems Australasia Pty Ltd