Investigation was carried out to this incident and the conclusions are following.On october 21, 2018, arjo was informed by a nurse that the chest proning pack buckle on the rotoprone bed would not release.The attempts to release buckle by pushing in on proning pack side arms were not effective.The patient was not tolerating being in supine position, thus the patient was placed in prone position for further treatment.Information about the patient's condition and how the situation was handled is unknown.No injury was reported as a result of the issues.When reviewing previous complaints for buckle inability to open we were able to identify two situations in which buckle may not release: (1) mechanical failure of the buckle or (2) tension is built on the buckle release mechanism due to straps overtightening before the proning therapy or the patient can swell and push on the proning packs which generates extra tension in the straps.In the course of this investigation service records were reviewed by service technician, and we were able to confirm that when the bed returned from rental, no technical malfunction was identified and no parts were replaced.The asset was quality control (qc) checked when it returned from the rent and no issue was detected on that occasion.The rotoprone bed functioned as intended.Because of the absence of technical failure and parts replaced, it is possible to state that the most probable cause of the inability to unbuckle the proning chest pack buckle was tension built on this part.In summary, the arjo device played a role in the event as it was used for patient treatment.The bed failed to perform as intended as buckle could not release when buckle release mechanism was pressed.There was no injury reported in relation to this event.We report this incident to the competent authority because of potential for health impact if it recurs.
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