All instruments subject of the reported event were reprocessed prior to use.A steris service technician arrived onsite following the reported event to inspect the transfer carriage however, the facility was unable to identify which unit had the issue.The facility has multiple transfer carriages, and the facility's biomed department had fixed the wheel before the technicians arrival.The technician inspected all six units and found that several wheels on the transfer carriages were loose.The technician tightened the wheels, tested each transfer carriage, and found all units to be operating according to specification.The transfer carriages are not under contract for steris maintenance activities.The user facilities biomed department is responsible for all maintenance activities.The root cause of the reported event can be attributed to improper maintenance of the transfer carriages.While onsite the technician counseled the facility's biomed department on the proper use and maintenance of the transfer carriage specifically, properly tightening the wheels on the transfer carriages.No additional issues have been reported.
|