Monaco RTP System, software versions 5.10 and 5.11, Radiation Treatment Planning System

FDA Device Recall #Z-2091-2019 — Class II — July 3, 2019

Recall Summary

Recall Number Z-2091-2019
Classification Class II — Moderate risk
Date Initiated July 3, 2019
Status Ongoing
Voluntary Voluntary: Firm initiated

Recalling Firm

Firm Elekta Inc
Location Maryland Heights, MO
Product Type Devices
Quantity 1396 units

Product Description

Monaco RTP System, software versions 5.10 and 5.11, Radiation Treatment Planning System

Reason for Recall

When creating 3D plans using either MU or Dose weighting modes, if the user changes the number of fractions, rescales the plan and then changes the wedge angle, the Monitor Units are scaled incorrectly.

Distribution Pattern

worldwide

Lot / Code Information

all Monaco Radiation Treatment Planning units installed with software version 5.10 or 5.11

Other Recalls from Elekta Inc

Recall # Classification Product Date
Z-1233-2023 Class II Monaco RTP System. Used to make treatment ... Feb 28, 2023
Z-2563-2021 Class II Elekta Monaco - Product Usage: used to make tre... Sep 14, 2021
Z-2406-2021 Class II Monaco RTP System, Software Builds 5.40.00, 5.4... Jul 26, 2021
Z-1825-2020 Class II Elekta MONACO RTP Sytem, radiation treatment pl... Apr 16, 2020
Z-1826-2020 Class II Leksell Vantage Stereotactic System. Instrument... Mar 30, 2020

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.