CLINAC

Additional Manufacturer Narrative

INVESTIGATION FOUND THAT WHEN THE MACHINE WAS FIRST ACCEPTED IN MARCH OF 2005, IT HAD COUCH ROTATION SCALE (IEC601). IN SEPTEMBER OF 2005, A VARIAN FIELD ENGINEER CALIBRATED THE COUCH ROTATION SCALE FROM IEC601 TO IEC1217. THE TREATMENT PLANS AND ACTUAL PLANS OF THE 5 PATIENT'S REPORTED BY THE CUSTOMER TO BE MISTREATED WERE REQUESTED BY VARIAN MEDICAL SYSTEMS, BUT THE CUSTOMER HAS REFUSED TO SEND DETAILED INFO ABOUT THE PATIENT'S. THE FIELD SERVICE REP WAS NOTIFIED OF THIS INSTALLATION ERROR AND HAS BEEN RE-TRAINED. THE FIELD SERVICE ENGINEER INSTALLED THE CORRECT COUCH ROTATION SCALE.

Description of Event or Problem

IN 2007, THE CUSTOMER REPORTED TO A VARIAN FIELD ENGINEER THAT THE COUCH ROTATION MOVES INCORRECTLY WHEN HE TRIED TO MOVE THE COUCH ROTATION WITH AUTO SET UP. THE CUSTOMER REPORTED TO VARIAN THAT MOST ALL PATIENT'S THAT HAVE BEEN TREATED ON 0 DEGREE (I.E. THE COUCH ROTATION ANGLE IS THE SAME IN BOTH IEC601 AND IEC1217) OVER THE PERIOD FROM 2005 TO 2007. THERE ARE 5 PATIENT'S WHO RECEIVED AN INCORRECT DOSE. FOUR PATIENT'S OUT OF FIVE PT'S WERE TREATED WITH WHOLE-BRAIN IRRADIATION AND ONE PT WAS TREATED WITH BREAST CANCER. VARIAN WAS INFORMED BY THE DOCTOR THAT THERE PROBABLY WAS NO SERIOUS INJURY IN ASSOCIATION WITH THIS EVENT.