CUSTOMER RECEIVED AN INITIAL POSITION DEVIATION ERROR DURING TREATMENT AND COULD NOT CLEAR IT/PROCEED. CUSTOMER CALLED THE SERVICE ENGINEER WHO EXPLAINED HOW TO CLEAR THE FAULT ERROR MESSAGE. THE PHYSICIST CLEARED THE FAULT ERROR AND CONTINUED THE TREATMENT. LATER ON IN THE SAME TREATMENT, THE CUSTOMER RECEIVED ANOTHER INITIAL POSITION DEVIATION ERROR MESSAGE. THE TREATMENT LOG INDICATED THE CUSTOMER CLEARED THE FAULT ERROR MESSAGE AGAIN. CUSTOMER INITIATED A SERVICE CALL TO EVALUATE THE APS SINCE IT WOULD NOT PARK PROPERLY (UNLESS IN TRUNNION MODE). THE APS POSITION DEVIATION RESULTED IN A TREATMENT MISADMINISTRATION UP TO 5 MM FROM THE DESIRED TARGET.
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Patient 1
INVESTIGATION RESULTS: THE SERVICE ENGINEER INSPECTED THE APS AFTER TREATMENT WAS COMPLETED (THE APS WOULDN'T PARK PROPERLY). FOUND THE L & R X-AXIS WAS READING GREATER BY ABOUT 4-4.5 MM FROM THE DIGITAL READING OF 100. NOTICED ON THE TREATMENT LOG ERROR THERE WAS AN APSM SCALE JUMP OCCURRED DURING THE TREATMENT THAT NIGHT. TRIED PARKING THE MECHANICS AND PERFORMING QA TEST RUN SET-UPS, BUT IT WOULD NOT MOVE LESS THAN 104 ON BOTH MECHANICS. SCHEDULED FUTURE PRECISE TOOL CALIBRATION OF APS. CUSTOMER TREATED IN TRUNNION MODE UNTIL TEST TOOLS ARE RECEIVED. CURRENT USER MANUAL CONTAINS INSTRUCTIONS FOR ACCEPTING THE POSITION DEVIATION ERROR. AN UPDATE OF THE USER MANUAL INSTRUCTIONS FOR USE WILL BE MADE TO FURTHER EXPLAIN THE CONSEQUENCE IF USER BYPASSES THIS ERROR. THIS IS A PREVENTATIVE MEASURE TO PROVIDE MORE INFO TO THE USERS.