It was reported that ambulance was transporting patient, when user noticed that oxylog is still on the floor, so device was connected to equipment holder, while ambulance already moving.Both nurses checked that device was connected right, and could hear click noise, and one of them also checked it is not moving.When turning ambulance in curve in low speed, oxylog suddenly dropped down.It dropped to the bed, but corner of device touched patients forehead, and caused 3cm wound that needed to be stitched.Patient is ok after wound sutured.
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The affected equipment holder was provided for investigation.No damage could be found during analysis.The equipment holder was found fully functional during testing.As no malfunction could be found and no similar incidents have been reported to dräger in the past, it is likely that the oxylog 3000 has been inserted incorrectly.Thus, it led to an instable fixation that could not hold the device sufficiently when the ambulance was changing its direction.The correct mounting is clearly described in the ifu.
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