Model Number ORT 400 |
Device Problem
Signal Artifact/Noise (1036)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 10/12/2021 |
Event Type
malfunction
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Manufacturer Narrative
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The firm is investigating the observed phase shift or image distortion and factors such as eddy current compensation and protocol imaging parameters utilized, as well as potential eddy current interference from the operating room table.At this time a device malfunction has not been identified.A followup report will be submitted once the investigation has been completed.
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Event Description
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It was reported that during a magnetic resonance-guided litt procedure, the area intended for ablation appeared to be off target, prior to ablation.The case was completed and no patient or procedural impact or consequence was reported.The planned therapy was delivered after the neurosurgeon compensated for the observed shift in imaging.
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Manufacturer Narrative
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The root cause of this event was traced to user error of incorrect localizer settings; the first localizer settings were not zeroed out which led to an error impacting patient registration.The phase shift was reported to be observed prior to ablation therapy, after which coordinate adjustments were made and the procedure continued without further impact.A device malfunction was not identified during the investigation.
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Search Alerts/Recalls
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