The Recall Desk
HighFDA (Devices)·Z-2150-2016·Announced 2016-07-20

Varian AlignRT Plus Optical Surface Monitoring System Recall for Parameter Errors

Varian Medical Systems is recalling AlignRT Plus systems because unintended changes to couch rotation parameters can occur during patient set-up.

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 involves a high-risk medical device where unintended parameter changes could affect treatment accuracy, but the source text does not report any specific injuries or illnesses, fitting the 'High' criteria for risk-of-harm products without reported injury.

Plain-English summary

Varian Medical Systems, Inc. is recalling the AlignRT Plus Optical Surface Monitoring System (OSMS). This system is used on Varian's TrueBeam EDGE to position and monitor patients relative to the prescribed treatment isocentre and to automatically withhold the beam during radiation delivery.

The recall is due to reports that unintended changes were made to planned couch parameters, specifically the couch rotation parameter, during patient set-up. This issue can occur when a user sets a different couch rotation from the plan couch rotation while performing patient alignment with the OSMS.

The recall affects 21 AlignRT Plus units in the United States and 1 unit internationally. Distribution includes the US (nationwide) and countries including Austria, Azerbaijan, Brunei Darussalam, Bulgaria, Denmark, Georgia, Germany, India, Italy, Malaysia, Morocco, Norway, Portugal, Switzerland, and the United Kingdom. Affected units are identified by specific serial numbers listed in the agency record.

The recalled product

Product
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 radi

Distribution

Distributed nationwide across the United States.

Part of a larger recall action

This product is one of 2 recalled by Varian Medical Systems, Inc. under a single FDA (Devices) recall action. The agency files each product separately, so the size of the action is not visible from this page alone.

See all 2 products in this recall →

Same hazard · parameter error

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