Oncentra Brachy Planning, Record no. 80569320017, Annex I: Products Affected 의 안전성 경고

Agência Nacional de Vigilância Sanitária (ANVISA)에 따르면, 해당 안전성 경고 는 Brazil 에서 Elekta Medical Systems Comércio e Serviços para Radioterapia Ltda. 에 의해 제조된 제품과 관련되어 있습니다.

이것은 무엇인가요?

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
    1605
  • 날짜
    2015-06-03
  • 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
    According to the company's statement, the magnitude of the error of calculation of the dose depends on the transformation of the registry and may range from 0 to 100% of the correct dose value. We have identified two clinical scenarios in which the problem may impact patient care: 1. Multi-modal imaging prior to the first fraction, in which the secondary data sets are used in contour definition and dose assessment. 2. Pre-treatment image examinations and plan adjustment based on contour definition and dose evaluation in the secondary data set (pretreatment). The isodose line function, which is commonly used for dose assessments in conjunction with the dose assessment functions mentioned above, is not affected by this problem. The company also reports that the problem was discovered during the introduction of a new treatment protocol at a client center on March 18, 2015. The client perceived the problem directly when comparing the DVH values ​​with the isodose lines during the evaluation plan. ##### Update of the field action: UPDATED ON 11/03/2017, the company presented the completion report of the field action, with sending of necessary evidences and corrective actions.
  • 원인
    The manufacturer of the product has identified the possibility of incorrect dose calculations for regions of interest (rois) defined in a secondary series of images. it has been determined that the software may cause incorrect dose values ​​or display an incorrect dose when the following conditions are satisfied: 1. the identity recording method is not used, and 2. a treatment plan contains a primary series of images a and one or more secondary series of images b, and 3. the set of data b is recorded in data set a by means of an image registration procedure: surface compatibility, and 4. an roi is defined in data set b. the dose or dose values ​​displayed may be incorrect in some of the functions of the secondary series of pictures: • dose profile; • dvh chart (for rois in secondary images); • dvh table values ​​(in rois in secondary images); • dose statistics in case explorer (in rois in secondary images); • hipo (with rois in secondary images) note: there was no impact to patients or chance of impact to patients, even if the procedure had been continued.
  • 조치
    The company that registers in Brazil is directed to repeat sampling of Regions of Interest defined in a secondary series of images in the primary series of images before the dose evaluation. Further information: Annex II - Letter to the Client

Manufacturer