inforMED
MalfunctionIZZ

COMPAX 400

Received Jan 11, 2009 · Event occurred Nov 4, 2008

Report 9611343-2009-00007 · MDR key 1311013

Device

Model number

46-909330G01

Catalog number

NA

Lot number

NA

Product problems

  • Unintended System Motion

Patient

NA

  • No Known Impact Or Consequence To Patient

Narrative

Description of Event or Problem

IT WAS REPORTED THAT THE TABLE LOCKS WERE NOT ACTUATING WHEN THE FOOT PEDAL WAS RELEASED, CAUSING THE TABLETOP UNEXPECTEDLY MOVE IN BOTH LONGITUDINAL AND LATERAL DIRECTIONS WITHOUT RESISTANCE (FREE FLOAT). THE ISSUE WAS DISCOVERED DURING SET-UP. THERE WAS NO INJURY REPORTED. THIS SITUATION COULD CONTRIBUTED TO AN INJURY IF A PATIENT OR OPERATOR WERE UNAWARE OF THIS CONDITION WHILE LOADING OR UNLOADING A PATIENT. THE ENSURING INSTABILITY COULD LEAD TO A FALL.

Additional Manufacturer Narrative

GE FIELD ENGINEER (FE) FOUND THAT THE UNEXPECTED FLOAT WAS DUE TO LOSS OF POWER TO THE TABLE LOCKS. THE POWER LOSS WAS CAUSED BY A BROKEN CABLE. THE FE REPLACED THE CABLE AND VERIFIED THAT THE TABLE LOCKS WERE PERFORMING ACCORDING TO SPECIFICATIONS.