inforMED
MalfunctionKZF

HARMONY LED385 EXAMINATION LIGHTING SYSTEM

Received Jun 17, 2022 · Event occurred May 20, 2022

Report 1043572-2022-00044 · MDR key 14732898

Device

Generic name

Lighting System

Product problems

  • Installation-Related Problem
  • Installation-Related Problem

Patient

Unknown

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Description of Event or Problem

THE USER FACILITY REPORTED THAT THEIR HARMONY LED385 EXAMINATION LIGHTING SYSTEM DETACHED FROM THE CEILING. NO PATIENTS OR EMPLOYEES WERE IN THE ROOM AT THE TIME OF THE EVENT. NO INJURIES OR PROCEDURE DELAYS WERE REPORTED.

Additional Manufacturer Narrative

A STERIS SURGICAL SERVICE REPRESENTATIVE INSPECTED THE LIGHTING SYSTEM AND FOUND THAT IT WAS NOT INSTALLED PROPERLY. STERIS DID NOT INSTALL THE HARMONY LED385 EXAMINATION LIGHTING SYSTEM SUBJECT OF THE REPORTED EVENT. THE LIGHTING SYSTEM WAS INSTALLED BY THE USER FACILITY'S SUBCONTRACTOR IN (B)(6) 2013. THE STERIS SURGICAL SERVICE REPRESENTATIVE FOUND THAT THE TUBE SUSPENSION HAD NOT BEEN DRILLED PROPERLY BY THE SUBCONTRACTOR AT THE TIME OF INSTALLATION ALLOWING THE SCREW AND ITS WASHER TO NOT ENGAGE INTO THE CEILING PLATE. THE HARMONY LED385 EXAMINATION LIGHTING SYSTEM SUBJECT OF THE REPORTED EVENT WAS REPAIRED AND RE-INSTALLED BY THE USER FACILITY'S ENGINEERING DEPARTMENT. STERIS REQUESTED ACCESS TO THE EQUIPMENT TO ENSURE THE LIGHTING SYSTEM WAS REPAIRED AND INSTALLED PROPERLY HOWEVER, THE USER FACILITY DECLINED STERIS ACCESS TO THE ROOM. THE STERIS SURGICAL SERVICE REPRESENTATIVE PROACTIVELY INSPECTED ALL OTHER HARMONY LED385 EXAMINATION LIGHTING SYSTEMS AND FOUND THAT THEY WERE NOT INSTALLED CORRECTLY PER STERIS EQUIPMENT MAINTENANCE REQUIREMENTS. A STERIS SERVICE TECHNICIAN WAS ABLE TO MAKE REPAIRS AND ADJUSTMENTS TO THE USER FACILITY'S OTHER HARMONY LED385 SURGICAL LIGHTING SYSTEMS. THE LIGHT SYSTEMS WERE TESTED AND CONFIRMED TO BE OPERATING ACCORDING TO SPECIFICATIONS. THE STERIS EQUIPMENT MAINTENANCE REQUIREMENTS HARMONY LED 385 LIGHT PREVENTATIVE MAINTENANCE CHECK LIST (764327-327) REV. 2 12/23/13 STEP 5.0 FINAL TESTING/ADMIN - PERFORM AT EACH MAINTENANCE INSPECTION. SUB-SECTION 5.1 - CHECK FOR PROPER INSTALLATION. FOR CEILING MOUNT UNITS, REMOVE CANOPY AND CHECK FOR TIGHTNESS OF MOUNTING SCREWS AND THAT THE VERTICAL TUBE AND PLATE ARE SECURE. STERIS DISCONTINUED THE HARMONY LED385 EXAMINATION LIGHTING SYSTEM IN (B)(6) 2017. NO ADDITIONAL ISSUES HAVE BEEN REPORTED.