ViewRay System: Model No. 10000 and 20000 for radiation treatment. PN11440 MRIdian System Treat...

FDA Device Recall #Z-1803-2020 — Class II — November 18, 2019

Recall Summary

Recall Number Z-1803-2020
Classification Class II — Moderate risk
Date Initiated November 18, 2019
Status Terminated
Voluntary Voluntary: Firm initiated

Recalling Firm

Firm Viewray, Inc.
Location Mountain View, CA
Product Type Devices
Quantity 32

Product Description

ViewRay System: Model No. 10000 and 20000 for radiation treatment. PN11440 MRIdian System Treatment Planning and Delivery System (TPDS) software

Reason for Recall

Registering dose and structures in the treatment delivery workflow could result in an alignment discrepancy between the imported previously delivered dose and the displayed patient anatomy and structures. The MRIdian TPDS software shows this misalignment to the user in the predicted dose-volume histogram (DVH). The misalignment impact may not be obvious to the user. During plan re-optimization the previously delivered dose would be incorrectly accounted for by the software. This may result in unexpectedly higher or lower dose than the intended dose calculated for the subsequent treatment plan. When this occurs in the treatment planning workflow, the registration fails to align the dose with the image and the user is unable to proceed.

Distribution Pattern

Worldwide distribution. US states of MO, WI, CA, FL, MI, NY, MI, IL, and MA. South Korea, Netherlands, Italy, Japan, Germany, UAE, Turkey, France, Israel, Denmark, Switzerland, and United Kingdom. The distributors are assigned to applicable regions. Firm send the Urgent Device Corrections to them and they forwarded them to the sites.

Lot / Code Information

Model No.10000 - Serial No's:. 100,104,105,112,113 Model No. 20000 - Serial No's: 101,102,107,108,200,201,203,204,206,207,209,211, 213,214,215,216,217,218,221,223,225,227,228,232,238,240,243, 244,247,250

Other Recalls from Viewray, Inc.

Recall # Classification Product Date
Z-1836-2021 Class II ViewRay MRIdian Linac System: Model No. 20000-0... May 4, 2021
Z-0481-2021 Class II ViewRay MRIdian System: Model No. 10000, CE, R... Oct 20, 2020
Z-0482-2021 Class II ViewRay MRIdian Linac System: Model No. 20000,... Oct 20, 2020
Z-1251-2019 Class II MRIdian Linac Radiation Therapy System, Model 2... Mar 18, 2019
Z-0676-2020 Class II MRIdian Linac Radiation Therapy System Model 10... Mar 3, 2019

Frequently Asked Questions

A software recall means the device's embedded software or firmware has a defect that could affect its performance or safety. Many software recalls are corrected through firmware updates that can be applied without physically replacing the device. For implantable devices, the update may be delivered wirelessly during a routine clinic visit. For external devices, the manufacturer may provide updated software files or replacement units. Contact your healthcare provider to determine whether your specific device and software version are affected and what action is recommended.

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.