inforMED
MalfunctionKPY

HARMONY RSHIELD RADIATION PROTECTION DEVICE

Received Dec 28, 2020 · Event occurred Dec 2, 2020

Report 1043572-2020-00067 · MDR key 11079396

Device

Generic name

Shield

Product problems

  • Detachment of Device or Device Component

Patient

Not reported

  • Insufficient Information
  • Insufficient Information

Narrative

Additional Manufacturer Narrative

A STERIS SERVICE TECHNICIAN ARRIVED ONSITE TO INSPECT THE LIGHTING SYSTEM AND CONFIRMED THE SHIELD HAD DETACHED. THE LIGHTING SYSTEM WAS INSTALLED IN 2013 MAKING IT APPROXIMATELY 7 YEARS OLD AND IS NOT UNDER STERIS SERVICE AGREEMENT; THE USER FACILITY IS RESPONSIBLE FOR ALL MAINTENANCE ACTIVITIES. THE TECHNICIAN REATTACHED THE RADIATION SHIELD, TESTED THE LIGHTING SYSTEM, CONFIRMED IT TO BE OPERATING ACCORDING TO SPECIFICATION, AND RETURNED IT TO SERVICE. A 3-YEAR COMPLAINT REVIEW INDICATES THIS TO BE AN ISOLATED EVENT. NO ADDITIONAL ISSUES HAVE BEEN REPORTED.

Description of Event or Problem

THE USER FACILITY REPORTED THAT AS AN EMPLOYEE ATTEMPTED TO MOVE THE HARMONY RSHIELD RADIATION PROTECTION DEVICE ATTACHED TO THEIR HARMONY LED SURGICAL LIGHTING SYSTEM, THE SHIELD SUBSEQUENTLY DETACHED FROM THE LIGHTING SYSTEM. THE EMPLOYEE CAUGHT THE SHIELD AS IT DETACHED. NO REPORT OF INJURY.