ROTATING IV POLE
Received Apr 27, 2021 · Event occurred Apr 14, 2021
Report 11731527 · MDR key 11731527
Device
Generic name
Stand, Infusion
Manufacturer
Ohmeda MedicalCatalog number
6600-0851-800
Lot number
LAU14256889
Product problems
- Break
- Device Fell
Patient
Not reported
- No Clinical Signs, Symptoms or Conditions
- No Clinical Signs, Symptoms or Conditions
Narrative
Description of Event or Problem
NURSE REPORTED SHE WAS PUTTING AN OXYGEN FLOW MONITOR ON THE WALL BEHIND AN INFANT WARMER IN THE WELL-BABY NURSERY. SHE MOVED THE OHMEDA MEDICAL ROTATING IV POLE OUT OF THE WAY (WHICH IS ATTACHED TO THE INFANT WARMER) AND IT ALL SNAPPED OFF AND FELL. NURSE CHECKED THE SCREWS THAT SECURE THE ROTATING IV POLE TO THE WARMER AND THE METAL HOLDING IT TOGETHER HAD BROKEN. THE WEIGHT LIMIT FOR THE POLE IS 9 KG. THE TWO INFUSION DEVICES ON THE ROTATING IV POLE HAD A COMBINED WEIGHT OF 4.21 KG WHICH IS LESS THAN THE WEIGHT LIMIT. IF THERE HAD BEEN A BABY IN THAT WARMER IT COULD HAVE SEVERELY INJURED THE BABY. CLINICAL ENGINEERING COMPLETED AN INVESTIGATION OF THIS EVENT AND FOUND THAT THE INTERNAL SLEEVE IN WHICH THE BOLT THAT SECURES CLAMPING PART TO THE POLE WAS SHEARED OFF.