RecallDepth

Monaco Radiation Treatment Planning (RTP) System

Company
Elekta, Inc.
Recall Initiated
February 8, 2019
Terminated
August 19, 2024
Recall Number
Z-0965-2019
Quantity
14 devices
Firm Location
Atlanta, GA

Reason for Recall

If Improve Target Dose was chosen as an optimization model in a previous treatment session, Monaco will automatically use this optimization model again when proceeding with the online plan adaptation of a completion plan when it should not.

Distribution

Domestic distribution to Wisconsin, Texas. International distribution to Denmark, England, Germany, Netherlands, Sweden.

Lot / Code Info

Software version 5.40

Root Cause

Software design

Action Taken

Elekta notified customers on about 2/08/2019 via "URGENT IMPORTANT FIELD SAFETY NOTIFICATION." Instructions included to ensure the optimization model is set to "Reproduce Goal Dose" when creating a completion plan. Customers were also requested to post the recall notice in an accessible place for all users to see, advise the appropriate personnel working with the device of the recall, and to complete and return the Acknowledgement Form. The issue will be resolved in Monaco release 5.40.01.

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