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Model Number GAB1011-01-EU
Device Problems Use of Device Problem; Device Tipped Over
Event Date 10/03/2016
Event Type  Malfunction  
Manufacturer Narrative

(b)(4). This appears to be a "malfunction" type of event not because there was a technical malfunction of the device, but since due to a use error the device did not perform as intended. Additional information will be provided following the conclusion of the investigation.

Event Description

Following the information provided, upon competition of the bathing procedure, the resident was transferred from the pool using the entroy pool lift and placed into the entroy hygiene chair. During the resident transfer towards the changing room, using the entroy hygienic chair, the device was reported to lost its stability and tipped forward. As a consequence of this event, the resident fell forward on the floor. The resident suffered bruises on the armrests and on the waist left side.

Manufacturer Narrative

(b)(4). Please note that previous medwatch reports for this product may have been submitted for the manufacturing site arjo hospital equipment (b)(4) (under registration #9611530). As of 2014 that number was de activated due to the site no longer shipping product to the usa. From 2014 and going forward complaints related to these products are to be handled by arjohuntleigh (b)(4)'s complaint handling establishment and any medwatch reports will be submitted under registration #3007420694. This appears to be a "malfunction" type of event not because there was a technical malfunction of the device, but since due to a use error the device did not perform as intended. An investigation was carried out into this complaint. When reviewing similar reportable events for entroy, we have found a low number of other similar cases where seat or stretcher detached from entroy's lifting arm or a base. There is very low complaint ratio for this kinds of events in last 5 years. The device was inspected by an arjohuntleigh representative at the customer site and found to be to the specification - no fault was found that caused or contributed to the event. The detailed device's assessment made by the service technician showed that there are marks that were most likely related to incorrect docking of a seat. Product's instruction for use (ifu) is provided with each device. Ifus (operating and product care instructions 04. Ga. 05/ 6gb from september 2005 for entroy and 04. Ga. 06/2gb from january 2003 for entroy chair with chassis) inform that user must always make sure that: "the entroy chair and the entroy stretcher are properly docked onto the pool lift or a chassis. " please note that product's [. ] operating and product care instructions' informs about correct docking of a seat: "to prevent unintentional release of the chair, a docking handle is [?]tted on the back of the transfer mechanism. This should be pulled out to release the quick coupling and pressed in when locking it. An indicator window shows green or red colour. " instructions include also correct docking procedure of a seat: " place the pool lift arm in the correct position over the area intended for transfer. Lower the pool lift arm until the docking tap is at a height just below the docking hole of the entroy chair /entroy stretcher. Position the chair chassis/ stretcher chassis in front of the pool lift. It is very important that the arrows are pointing transversely to each other so that the chair/stretcher including chassis is positioned in a 90° angle in relation to the lift arm. Slowly raise the pool lift arm. Check that the docking tap meets the docking hole in the chair/stretcher properly. [. ] put one foot on the chassis to stabilize. Pull the handle. Raise the pool lift arm slowly and release/push the handle after raising about 50 mm. Check that the docking tap has engaged fully in the docking hole. Note! normally the chassis will leave the floor for maximum 50 mm before the quick coupling releases. This will cause a small bump. Check that the indicator on the handle is totally green before the raising is continued. Warning! never raise the pool lift arm if the indicator is red or partly red. If the chassis will be lifted off the floor it can cause injury if it disconnects and falls down. Move away the entroy chair/stretcher chassis. " please note that the possibility of incorrect docking was indicated by the service technician based on the marks of the equipment: "it is likely, user error. Staff have probably brought out the locking handle too early and not seen that it is not docked right on the base and then has already entroy docked off. This allows the chair's seat to rotate the legs off the chair to become unstable with the result of rollover risk. " from above, we can conclude that this problem was most likely caused by user error - user did not follow warnings regarding correct docking and preserving patient's safety. The received information and our evaluation as described above are showing that if entroy's warnings and transferring procedures were followed in accordance to instruction for use and, there would be no patient or caregiver at risk. The device was up to manufacturer's specification at the time of event. It was being used for patient treatment and by this contributed to this event.

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Brand NameENTROY
Manufacturer (Section D)
verkstadsvagen 5
eslov, 24121
SW  24121
Manufacturer (Section G)
verkstadsvagen 5
eslov, 24121
SW  24121
Manufacturer Contact
pamela wright
12625 wetmore, ste 308
san antonio , TX 78247
MDR Report Key6064654
Report Number3007420694-2016-00227
Device Sequence Number1
Product CodeFNG
Report Source Manufacturer
Reporter Occupation
Remedial Action Other
Type of Report Initial,Followup
Report Date 11/25/2016,10/03/2016
1 Device Was Involved in the Event
1 Patient Was Involved in the Event
Date FDA Received10/28/2016
Is This An Adverse Event Report? Yes
Is This A Product Problem Report? Yes
Device MODEL NumberGAB1011-01-EU
Was Device Available For Evaluation? Yes
Is The Reporter A Health Professional? No
Was the Report Sent to FDA? Yes
Date Report Sent to FDA11/25/2016
Distributor Facility Aware Date10/03/2016
Device Age10 yr
Event Location Outpatient Treatment Facility
Date Report TO Manufacturer11/25/2016
Date Manufacturer Received10/03/2016
Was Device Evaluated By Manufacturer? Device Not Returned To Manufacturer
Date Device Manufactured07/31/2006
Is The Device Single Use? No
Is this a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Reuse

Date Received: 10/28/2016 Patient Sequence Number: 1