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U.S. Department of Health and Human Services

Class 2 Device Recall Pinnacle3

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  Class 2 Device Recall Pinnacle3 see related information
Date Initiated by Firm August 30, 2022
Date Posted September 15, 2022
Recall Status1 Open3, Classified
Recall Number Z-1744-2022
Recall Event ID 90819
510(K)Number K170086  
Product Classification System, planning, radiation therapy treatment - Product Code MUJ
Product Pinnacle3 Radiation Therapy Planning System, Model numbers 870231 and 870237.
Code Information Model 870231: Software version 16.0.4, UDI (01)00884838099081(10)16.0.4.60330; Software version 16.4.2, UDI (01)0084838103054(10)16.4.2.60330, UDI (01)00884838102965(10)16.4.2.60330, UDI (01)00884838102972(10)16.4.2.60315, UDI (01)00884838102989(10)16.4.2.60330; UDI (01)00884838103191(10)16.4.2.60330; and Software version 16.4.3, UDI (01)00884838102965(10)16.4.3.60360. Model 870237: Software version 16.4.6, UDI (01)00884838103566(10)16.4.6.21197; and Software version 18.0.1, UDI (01)00884838103566(10)18.0.1.2149 and (01)00884838103566(10)18.0.1.21197.
Recalling Firm/
Manufacturer		 Philips Medical Systems (Cleveland) Inc
3630 Sw 47th Ave
Gainesville FL 32608-7555
For Additional Information Contact Philips Customer Care Solutions Center
800-722-9377
Manufacturer Reason
for Recall		 When computing a radiation dose in the system, the exported dose information is incorrect when there is more than one beam attached to the prescription and certain options are selected on the Edit Prescription screen.
FDA Determined
Cause 2		 Device Design
Action The recalling firm issued letters dated August 2022 via certified mail on 8/30/2022. A black box at the beginning of the letter notates the document contains important information for the continued safe and proper use of the product. The information is to be reviewed with all members of the consignee's staff who need to be aware of the contents of the communication and to understand the implications of the communication. The letter informs the consignee what the problem is and under what circumstances it can occur and contains an embedded photograph of the Edit Prescription screen highlighting the affected fields. The hazard/harm associated with the issue is described, as well as the affected products and how to identify them. An embedded example of the About screen is contained in the letter to show where to find the affected version number. The actions to be taken by the customer/user in order to prevent risks for patients was provided. The actions include: (a) To avoid exporting an incorrect dose, do not prescribe to Percentage of Point Dose. Only prescribe plans using one of the following options provided in the letter until the software solution is provided by Philips; (b) Circulate the notice to the Head of Medical Physics in the Radiation Oncology Department or to the Department Director with specific instructions that the notice be distributed to all users of the Pinnacle3 Radiation Therapy Planning System so that they are aware of the product issue and associated hazard/harm; (c) Post the notice near the affected Pinnacle3 Radiation Therapy Planning System(s) for ease of reference; and (d) Complete and return the attached response form to Philips via email no later than 30 days from receipt of the letter. The consignee is informed that Philips is currently developing a correction which will be released in the future and once released, Philips will contact the consignee to schedule installation of the software solution to resolve the issue.
Quantity in Commerce 169 systems
Distribution Distribution was made to CA, FL, GA, IA, IL, MA, MD, ME, MI, MN, NJ, NM, NV, NY, OH, OK, RI, SC, TN, TX, and WA. There was government distribution and no military distribution. Foreign distribution was made to Australia, Austria, Belgium, China, France, Germany, Italy, Japan, Jordan, Lebanon, Poland, Portugal, Romania, Russian Federation, Singapore, Spain, Switzerland, Taiwan, Thailand, and United Kingdom.
Total Product Life Cycle TPLC Device Report
1 A record in this database is created when a firm initiates a correction or removal action. The record is updated if the FDA identifies a violation and classifies the action as a recall, and it is updated for a final time when the recall is terminated. Learn more about medical device recalls.
2 Per FDA policy, recall cause determinations are subject to modification up to the point of termination of the recall.
3 The manufacturer has initiated the recall and not all products have been corrected or removed. This record will be updated as the status changes.
510(K) Database 510(K)s with Product Code = MUJ and Original Applicant = Philips Medical Systems (Cleveland), Inc.
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