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A steris service technician arrived onsite following the reported event to inspect the unit.User facility personnel stated to the technician that the loading cart was not properly latched to the washer causing the rack to fall.When the employee removed the rack from the washer, they did not pull the rack far enough back onto the cart for the locks to fully engage when the cart was removed from the washer's docking station.Therefore, once the cart was removed with the rack on top of it, the rack slid off the end of the cart.The employee tried to catch the rack from falling and received a laceration to their hand.The technician inspected the loading cart and confirmed it was operating properly; no repairs were required and the unit was returned to service.The instructions for use (ifu) include the following statement about proper unloading washer/disinfector, "for manual unloading of washer/disinfector (without atlas workflow automation vehicle or scs conveyor on unload side), proceed as follows: bring a transfer cart next to washer/disinfector unload door and ensure transfer cart brakes are applied (fd61-700 or fd199 for 7052hp w/d and fd179 for 7053hp w/d), ensure appropriate transfer cart wheels are locked and swiveling is not possible, ensure transfer cart is at the proper height, carefully pull accessory rack onto transfer cart and press close door to close unload door." steris counseled the user facility on the proper use and operation of the loading carts and instrument racks.No additional issues have been reported.
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