The Recall Desk
HighFDA (Devices)·Z-2315-2021·Announced 2021-08-25

CT5000 X-ray System Contrast Dose Calculation Error Under Pounds Setting

Philips CT5000 X-ray systems may incorrectly calculate contrast volume doses when patient weight units are set to pounds. The software error could recommend higher-than-intended contrast volumes.

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: This is an FDA Class II medical device with a software error that results in incorrect dosing calculations. While no illnesses have been reported, the error could result in increased contrast exposure affecting patient safety, fitting the criterion of a risk-of-harm product where injury has not yet been reported.

Plain-English summary

This recall involves 2 Philips CT5000 Ingenuity Plus/Pro/Premium Computed Tomography X-ray systems. The systems are affected by a software issue in the SynchRight P3T (Personalized Patient Protocol) module.

When a patient weight unit preference is set to pounds, the SynchRight software incorrectly calculates the recommended contrast volume, resulting in recommendations for increased contrast volumes. This could potentially expose patients to higher-than-intended contrast doses.

The recalled systems are located in the states of Arizona, Florida, Louisiana, Minnesota, Nebraska, Nevada, New York, and Pennsylvania. Affected healthcare facilities should contact Philips for instructions on how to address this issue. No illnesses or injuries have been reported.

Facilities with affected systems should verify their weight unit settings and contact Philips North America LLC for guidance on correcting the software configuration or obtaining a software update.

The recalled product

Product
Model 728321/728323 CT5000 Ingenuity Plus/Pro/Premium-Computed Tomography X-ray system
Manufacturer
Philips North America Llc
Hazard
  • incorrect-dosing
  • contrast-overdose

Distribution

Distributed nationwide across the United States.