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Patient 1
THE INVESTIGATION WAS COMPLETED BY CONDUCTING A THOROUGH EVALUATION OF THE PRODUCT AND THE REPORTED INFORMATION. THE ISSUE WAS DETERMINED TO BE A DEFECT IN THE PRODUCT. THE INVESTIGATION FOUND THAT ON THE MONACO BEAM SPREADSHEET, IT IS POSSIBLE TO SET THE FIELD SIZE FOR A BEAM TO SYMMETRIC (FOR A 3D PLAN) WHEN THE BEAM MODEL IDENTIFIES THE MACHINE JAWS AS ASYMMETRIC. THE DICOM EXPORT WILL READ THE BEAM SPREADSHEET VALUE (SYMMETRIC IN THIS CASE). THE IMPORTING SYSTEM COULD SET THE ASYMMETRIC BEAMS TO SYMMETRIC BASED ON THIS INFORMATION. THE INCORRECT FIELD WOULD BE TREATED WHICH COULD RESULT IN AN OVERDOSE OR UNDERDOSE OF THE PTV AND SUBSEQUENT OVERDOSE OR UNDERDOSE OF NORMAL STRUCTURES. DOSE ERRORS COULD BE GREATER THAN 5%. THE PROBABILITY OF THIS OCCURRING IS IMPLAUSIBLE. QA CHECKS BY THE USER AND CLINICAL QA WOULD BE VERIFYING THAT THE FIELDS PLANNED/CALCULATED ON MONACO WERE CORRECTLY TRANSFERRED TO MOSAIQ. THE FIELD SIZES SWITCHING FROM ASYMMETRIC ON MONACO TO SYMMETRIC IN MOSAIQ WOULD BE OBVIOUS AND SHOULD BE NOTICED BY THE DOSIMETRIST, PHYSICIST AND RADIATION THERAPIST. THE CUSTOMER IS USING AN OLD VERSION OF MOSAIQ (SOFTWARE VERSION 2.50.5.D7SP20) AND WITH THE DEFECT IDENTIFIED THE INCORRECT FIELD WOULD BE TREATED WHICH COULD LEAD TO AN OVERDOSE OR UNDERDOSE OF THE PTV AND SUBSEQUENT OVERDOSE OR UNDERDOSE OF NORMAL STRUCTURES. IT IS UNLIKELY THAT THE SITE WOULD PROVIDE THE WRONG MACHINE DATA. IF THE WRONG DATA IS PROVIDED, ELEKTA'S BEAM MODELING PROCESS SHOULD CATCH THE ERROR WITH DATA VERIFICATION TESTS. IN ADDITION, THE USER SHOULD DETECT THE ERROR WHEN THEY ACCEPT THEIR BEAM MODEL AND RUN THEIR ON-SITE COMMISSIONING TESTS. FINALLY, WHEN COMPARING TREATMENT PLANNING SEGMENTS TO R&V SEGMENTS BEFORE TREATMENT, THE DISCREPANCIES SHOULD BE VERY OBVIOUS. NO PATIENTS WERE MISTREATED. THE DEFECT IN MONACO WILL BE FIXED IN A FUTURE RELEASE AND THE MOSAIQ DEFECT WAS FIXED IN 2.63 BETA 01 WHICH WAS RELEASED 15TH OCTOBER 2015.