The Recall Desk
HighFDA (Devices)·Z-1006-2018·Announced 2018-03-21

Brainlab ExacTrac Software Recall for Beam Authorization Misinterpretation Risk

Brainlab AG is recalling ExacTrac Patient Positioning System software versions 6.0 through 6.5 due to a risk of misinterpreting beam authorization when used with specific Varian accelerators.

What this means for you

Real risk of harm even if no illness or injury has been reported yet. Stop using the product and follow the agency's guidance.

Our severity reasoning: The recall is classified as FDA Class II and involves a risk of harm (misinterpretation of beam authorization) where injury has not yet been reported, fitting the 'High' severity criteria for risk-of-harm products.

Plain-English summary

Brainlab AG is recalling 587 ExacTrac Patient Positioning System software systems, versions 6.0, 6.1, 6.2, and 6.5. These systems are used to position patients for stereotactic radiosurgery or radiotherapy procedures. The recall is due to a potential risk of misinterpreting beam authorization via the Auxiliary Device Interface (ADI) when the software is used with Varian Clinac or Varian TrueBeam accelerators.

The hazard arises from the usage of workflows that deviate from the recommended specifications in the User manual. This deviation may result in the misinterpretation of beam authorization signals. The affected software was distributed worldwide.

Healthcare facilities using these systems should contact Brainlab AG for instructions on how to address the issue. The recall is classified as Class II by the FDA, indicating that use of the product may cause temporary or medically reversible adverse health consequences.

The recalled product

Product
ExacTrac versions 6.5 through 6.5 intended to be used to place patients at an accurately defined point within the treatment beam of a medical accelerator for stereotactic radiosurgery or radiotherapy procedures, in order to treat lesions, tumors and conditions anywhere in the bod
Manufacturer
Brainlab AG
Affected units
587

Distribution

Distribution scope not specified by the agency.