CLINAC RADIOTERAPIC LINEAR ACCELERATORS - Registration 10405410001 and HIGH POWER RADIOTHERAPY LINEAR ACCELERATOR CLINAC - Registration 10405410010, Serial Numbers as listed in the appendix. http://en.wikipedia.org/w/index.php?/ 의 안전성 경고

Agência Nacional de Vigilância Sanitária (ANVISA)에 따르면, 해당 안전성 경고 는 Brazil 에서 VARIAN MEDICAL SYSTEMS BRASIL LTDA. 에 의해 제조된 제품과 관련되어 있습니다.

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안전성 경고는 의료기기 제품과 관련된 중요한 정보와 권고사항을 담고 있습니다. 물론 안전성 경고가 배포되었다고 해서 해당 제품이 무조건 안전하지 않은 제품이라는 것은 아닙니다. 보건의료업계 종사자와 의료기기 사용자들에게 배포되는 안전성 경고에는 회수(recall)도 포함될 수 있습니다. 제조사가 안전성 경고를 작성하기도 하지만, 보건당국에서 작성하는 경우도 있습니다.

데이터에 대해 더 자세히 알아보기 여기
  • 사례 유형
    Safety alert
  • 사례 ID
    1067
  • 날짜
    2011-07-08
  • 사례 국가
  • 사례 출처
    ANVISA
  • 사례 출처 URL
  • 비고 / 경고
    Brazilian data is current through June 2018. All of the data comes from Anvisa, 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 data from the U.S. and Brazil.
  • 데이터 추가 비고
    Varian's TrueBeam Clinacs and Systems utilize "rigid" physical beam modifying wedges (here referred to simply as "wedges" and excluding the functionality of "dynamic" wedges). These wedges are manufactured in various angles, dimensions and materials, with different configurations of bases for top and bottom fittings and in different configurations for Clinacs with MLC and without MLC. Varian was aware of two recent incidents in which the body of a 30 degree steel upper wedge separated from the wedge base due to the failure of the fastening screws. These incidents did not cause serious injury and in both cases occurred in Clinacs that had been in use for at least 7 (seven) years. In addition, at least one of the wedges had a history of periodic loosening of the fastening and re-tightening screws by the operator. It is likely that, at first, the fault only affects one or two fastening screws, leaving the wedge suspended by the remaining ones, which is a strong indication that others may fail. There are no records of occurrences in Brazil to date. Anvisa follows this field action.
  • 원인
    Separation between the wedges and their bases may occur. see annex: http://portal.Anvisa.Gov.Br/wps/wcm/connect/eedd6200478d48358e018e5c9a854df2/alerta_1067_aviso_de_seguranca.Pdf?mod=ajperes.
  • 조치
    To Users and Professionals: (1) Inspect all rigid wedges immediately to identify any missing or cracked screws. If any wedge has one or more missing or cracked screws, put the wedge out of use and notify the company immediately. (2) Inspect all rigid wedges to identify loose screws and tighten if necessary. (3) Implement a program of monthly wedge inspections to detect loose or missing components. Company action plan: (1) Referral of Urgent Security Notice (attached) to customers; (2) Replacement of screws on all rigid wedges, according to a schedule established by the company (until March / 2012), in Clinacs installed before January 2004; (3) Analysis of the problem and subsequent communication to the clients about the conclusions.

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