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The initial reporter was hospital maintenance personnel.Event site city: (b)(6).Event site telephone: (b)(6).Getinge became aware of an issue with one of surgical lights - volista access.It was stated that paint was damaged on fork and suspension arm.The designated complaint unit employee confirmed based on photographic evidence the paint was chipping on suspension arm and also indicated paint chipping and rust on spring arm, suspension arm and main tube.There was no injury reported, however, we decided to report the issue in abundance of caution as any particles falling off into sterile field or during procedure may cause contamination in case of reoccurrence.Based on the information collected, it was established that when the event occurred, the surgical lights did not meet its specification, since rust occurrence and paint chipping could be considered as technical deficiencies, and in this way the device contributed to event.It is unknown if claimed devices were or were not being used for patient treatment or diagnosis when the event took place.As stated by the subject matter expert, peeling paint and rust formation were probably caused by: - a stagnation of aggressive disinfectant and detergent products due to an inappropriate cleaning protocol.- the presence of liquid water or an exposure to humid air due to a high relative humidity of the operating room.The instruction for use indicates the environmental condition for use, the relative humidity must be between 20% and 75%.To prevent any incident the instruction for use mentions to perform daily and monthly inspection in order to detect painting defects, impact marks or other damages.The instruction for use mentions not to clean the device under running water nor spray a solution directly onto the device.Certain cleaning products or procedures may damage the paintwork of the device, which may result in particles falling onto the surgical site during an operation.Fumigation methods are unsuitable for disinfecting the unit and must not be used.The instruction for use mentions to wipe with a dry cloth and to make sure no liquid residue is left on the device after cleaning.To reduce the appearance of rust or the degradation of the surface, the technical manual or maintenance manual mentions in the preventive maintenance protocol to lubricate some parts of device.The instruction for use mentions not to use a damaged device because it may lead to a risk of injury for users or a risk of infection for patients.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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Getinge became aware of an issue with one of surgical lights - volista access.It was stated that paint was damaged on fork and suspension arm.The designated complaint unit employee confirmed based on photographic evidence the paint was chipping on suspension arm and also indicated paint chipping and rust on spring arm, suspension arm and main tube.There was no injury reported, however, we decided to report the issue in abundance of caution as any particles falling off into sterile field or during procedure may cause contamination in case of reoccurrence.
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