The Recall Desk
HighFDA (Devices)·Z-2667-2016·Announced 2016-08-31

Vision RT AlignRT Plus System Recalled for Unintended Couch Parameter Changes

Vision RT Ltd is recalling 47 AlignRT Plus systems because unintended changes to couch rotation parameters were discovered during patient set-up. No patient harm was reported.

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 (radiation therapy) where a defect could lead to harm, but the source explicitly states that no patient harm or serious injury was reported in the identified cases, fitting the 'High' severity criteria for risk-of-harm products without reported injury.

Plain-English summary

Vision RT Ltd is recalling 47 units of the AlignRT Plus system (private label-OSMS, model K123371). The device is indicated for use to position and monitor patients relative to the prescribed treatment isocentre and to automatically withhold the beam during radiation delivery. The recall was initiated after the manufacturer received three reports from different sites indicating that unintended changes were made to planned couch parameters, specifically the couch rotation parameter, during patient set-up.

The affected units were distributed in the United States, Canada, Germany, Japan, Sweden, Switzerland, Taiwan, and the United Kingdom. No product was distributed to US government accounts. The specific serial numbers of the affected devices are listed in the official recall notice.

No patient harm or serious injury was reported in any of the three cases that triggered the recall. The agency classification for this recall is Class II. Users of the affected devices should contact Vision RT Ltd for further instructions regarding the recall and corrective actions.

The recalled product

Product
AlignRT¿ Plus [private label-OSMS] K123371: 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 radiation delivery.
Manufacturer
Vision RT Ltd
Affected units
47

Distribution

Distribution scope not specified by the agency.

Part of a larger recall action

This product is one of 2 recalled by Vision RT Ltd 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 →