InjuryLMD
STENTOR PACS
Received Aug 10, 2011 · Event occurred Jul 25, 2011
Report MW5021724 · MDR key 2213259
Device
Generic name
Stentor Pacs
Manufacturer
Philips, StentorProduct problems
- Patient Data Problem
Patient
55 YR
- No Known Impact Or Consequence To Patient
Narrative
Description of Event or Problem
THE PT HAD HAD PRIOR INTRACRANIAL NEUROSURGERY FOR BRAIN CANCER. THE PT UNDERWENT INTERVAL BRAIN MRIS TO ASSESS INTERVAL CHANGE, IF ANY. WHEN AN MRI OF THE BRAIN WAS PERFORMED FOR NEW ONSET APHASIA, THE PACS DEVICE BROUGHT UP A PRIOR MRI FOR COMPARISON WHICH WAS PERFORMED MORE THAN A YEAR PRIOR AND WAS MORE ANCIENT THAN THE PAST THREE. THUS, THE ANALYSIS BY THE RADIOLOGIST WAS FLAWED, PUTTING THE PT AT RISK OF MIS-DIAGNOSIS AND CLINICAL ERROR IN TREATMENT.