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Getinge became aware of an issue with one of surgical lights - volista standop.It was stated the nursing staff found that a spring arm's screw from surgical light had fallen off during routine inspection.The hospital had installed the screws by itself, and the surgical lamp was in normal use.There was no injury.We decided to report the issue in abundance of caution as any parts falling off into sterile field or during procedure may cause contamination or serious injury.Based on the information collected, it was established that when the event occurred, the surgical lights did not meet its specification, since loose/missing screw from spring arm cover could be considered as technical deficiencies, and in this way the device contributed to event.A root cause analysis was performed by subject matter experts at the manufacturing site.As they stated it was detected that the screw on the spring arm cover was loose.This screw is responsible for attaching the cover to the spring arm structure.The manufacturer of the spring arms, ¿ondal¿, led several tests on a spring arm performing 20.000 cycles of up and down movement.The test with a loosened screw, with a complete turn back, shows that it is the only case where the screw continue to loosen.The cases detected after more than 1 year after the installation correspond to a lack of inspection during the yearly preventive maintenance.To prevent the loosening and the fall of the screw, the technical manuals indicate to check all the fixing screws and to check the hold of the spring arm covers during yearly preventive maintenance or daily inspections.The screw has a long threading, its loosening is visually detectable during cleaning or during yearly preventive maintenance.As improvement measure, since october 2019, the spring arms covers are assembled, on the product line, with tuflok coated screws.In any case, by design, the nylon patch of this screw acts as a mechanical locking and prevents the loosening and the fall of the screw.Getinge shall continue to monitor for any further events of this nature and does not propose any further action at this time.
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