inforMED
MalfunctionLMD

KDS COMPUTED RADIOGRAPHY SYSTEM 400

Received Jun 27, 1997 · Event occurred Jun 1, 1997

Report 1643366-1997-00001 · MDR key 101866

Device

Generic name

Computed Radiography

Model number

CR MODEL 400

Catalog number

8989774

Lot number

03669150, 3619138 K'S

Patient

63 YR

Narrative

Description of Event or Problem

IMAGE TRANSFER FROM THE KODAK EKTASCAN STORAGE PHOSPOR READER (KESPER) TO THE QUALITY CONTROL WORKSTATION (QCW) WAS NOT POSSIBLE DUE TO POTENTIAL DATABASE CORRUPTION INITIATED BY IMPROPER SHUTDOWN OF BOTH SYSTEMS BY HOSPITAL PERSONNEL. THE CR-400 SYSTEM (COMPUTED RADIOGRAPHY) MET ITS PERFORMANCE SPECIFICATIONS IN ACCORDANCE WITH ITS LABELING. THE MALFUNCTION WAS ATTRIBUTED TO USER ERROR. THE SYSTEMS WERE REBOOTED WITHOUT FOLLOWING THE APPROPRIATE RECOVERY INSTRUCTIONS. THE PT EXPIRED PRIOR TO THE SCANNING AND TRANSFER OF THE IMAGE ACCORDING TO HOSPITAL PERSONNEL.

Remedial action

  • Other