Device Problem
Device Fell (4014)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 08/28/2020 |
Event Type
malfunction
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Manufacturer Narrative
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All instruments were reprocessed prior to use.A steris service technician arrived onsite following the reported event to inspect the unit and found that the transfer carriage and docking station was damaged.Due to the damage observed, the transfer carriage and docking station were unable to be tested by the technician.Based on the description of the event, the employee did not properly align the transfer carriage with the sterilizer's docking station causing an inadequate latch of the transfer carriage's front wheels resulting in the reported event.The technician counseled user facility personnel on the proper use and operation of the evolution transfer carriage, specifically properly engaging the transfer carriage with the docking station.The technician replaced the docking station and ordered a replacement transfer carriage.No additional issues have been reported.
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Event Description
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The user facility reported that while an operator was unloading their sterilizer, the evolution transfer carriage fell to the ground.No report of injury.
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Manufacturer Narrative
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The unit subject of the event was returned to steris for evaluation and it was determined that the set screws were loose.The root cause of the reported event is attributed to impact damage by facility personnel which allowed the set screws to become loose.The transfer carriage subject of this event has been replaced.User facility personnel were counseled on the proper use and operation of the transfer carriage, including the importance of not bumping the transfer carriage into walls or other equipment.No additional issues have been reported.
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Search Alerts/Recalls
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