The transfer carriage subject of this event was returned to steris for evaluation and it was determined that the set screws of the front leg and caster assembly of the transfer carriage were loose.As the set screws were loose, the front leg and caster assembly was able to become unlocked resulting in the reported event.The root cause of the reported event is impact damage by facility personnel subsequently allowing the set screws to become loose.The technician counseled facility personnel on the proper use and operation of the transfer carriage, including the importance of not bumping the transfer carriage into other equipment.A replacement unit was installed and no additional issues have been reported.
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