Optical Surface Monitoring System{Align RT Plus} This is used on Varian's TrueBeam EDGE; Radio...
FDA Device Recall #Z-2150-2016 — Class II — June 23, 2016
Recall Summary
| Recall Number | Z-2150-2016 |
| Classification | Class II — Moderate risk |
| Date Initiated | June 23, 2016 |
| Status | Terminated |
| Voluntary | Voluntary: Firm initiated |
Recalling Firm
| Firm | Varian Medical Systems, Inc. |
| Location | Palo Alto, CA |
| Product Type | Devices |
| Quantity | 21 AlignRT Plus in US, 1 International. |
Product Description
Optical Surface Monitoring System{Align RT Plus} This is used on Varian's TrueBeam EDGE; Radiology: The AlignRT Plus system is indicated for use to position and monitor patients relative to the prescribed treatment isocentre, and to Withhold the beam automatically during radiation delivery.
Reason for Recall
Varian Medical Systems has received reports that unintended changes were made to planned couch parameters, specifically the couch rotation parameter, during patient set-up. This can occur when a user sets a different couch rotation from the plan couch rotation while performing patient alignment with Optical Surface Monitoring System [OSMS].
Distribution Pattern
Worldwide Distribution: US (nationwide) and countries of: Austria, Azerbaijan, Brunei Darussalam, Bulgaria, Denmark, Georgia, Germany, India, Italy, Malaysia, Morocco, Norway, Portugal, Switzerland, and United Kingdom.
Lot / Code Information
TrueBeam version 2.0/2.5 with any version OSMS. AlignRT Serial Numbers: 247-0200 247-0209 248-0013 248-0057 248-0070 249-0057 249-0066 249-0163 249-0164 249-0195 249-0226 249-0274 249-0050 249-0286 249-0277 248-0044 249-0227 247-0208 249-0047 247-0218 248-0050 248-0043 248-0048 249-0293 249-0155.
Other Recalls from Varian Medical Systems, Inc.
| Recall # | Classification | Product | Date |
|---|---|---|---|
| Z-1899-2020 | Class II | Varian Multileaf Collimator [MLC]; Millenium Mu... | Aug 12, 2019 |
| Z-0771-2019 | Class II | Eclipse(TM) Treatment Planning System with Prot... | Dec 26, 2018 |
| Z-0990-2017 | Class II | Eclipse Treatment Planning System version 13.MR... | Dec 2, 2016 |
| Z-0077-2017 | Class II | Varian Head Frame - Model number HHF -ALL Head ... | Sep 13, 2016 |
| Z-2149-2016 | Class II | Optical Surface Monitoring System{OSMS, Varian ... | Jun 23, 2016 |
Frequently Asked Questions
Contact your healthcare provider and the device manufacturer immediately. Check whether your specific model number and lot number are included in the recall scope. For external devices, stop using the affected product and arrange a replacement. For implanted devices, do not panic — removal is typically not required unless the risk assessment clearly indicates it. Your physician will guide you based on your individual clinical situation and the FDA's recommended actions. Report any adverse effects you may have experienced to FDA MedWatch at 1-800-FDA-1088.
Class I recalls indicate a reasonable probability of serious adverse health consequences or death from the defect. Class II recalls involve products that may cause temporary or medically reversible adverse health consequences, or where serious consequences are remote. Class III recalls cover products not likely to cause any adverse health consequences, typically involving technical regulatory violations. The classification guides urgency — Class I recalls require immediate action, while Class III may simply involve returning a product or acknowledging a labeling change. Always read the specific recall notice for recommended patient actions.
Report problems with medical devices to the FDA through MedWatch at 1-800-FDA-1088 or online at FDA.gov/safety/medwatch. Healthcare facilities are required by law to report device-related serious injuries and deaths. Patients and consumers can also report voluntarily. Include the device name, manufacturer, model number, and a description of the problem and any patient outcome. Reports from patients and clinicians help the FDA identify emerging safety signals and may trigger investigations that lead to recalls of dangerous devices.
What Should You Do?
Stop using this device if you are affected by this recall. Contact your healthcare provider and the manufacturer immediately for guidance. Report adverse events to FDA MedWatch.