The investigation was performed based on the initially provided information as neither the device log file nor the replaced kollmorgen motor were made available.It was just reported that the logs showed two error entries "motor slow" and "motor stalled" which indicate deviations in the motor's rotation speed.As specified for this situation and as reported the ventilator was stopped accompanied by a corresponding "vent fail" alarm.Manual ventilation is still possible and the patient status can be derived from the readings of the mandatory patient gas monitoring.Root cause can be traced back to the motor as its replacement has solved the reported issue.A more precise analysis which component in detail has caused the issue is not possible as the replaced motor was already discarded by the biomed on-site.As the motor is a wear-and-tear part it is imaginable that after 12 years in operation a single motor component can fail.Finally it can be concluded that the number of similar cases, related to the same root cause (kollmorgen motor), is within the expected range of the respective risk assessment and thus accepted.
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