SKYTRON ULTRASLIDE 3600B SURGICAL TABLE

Description of Event or Problem

EVENT: THE UNINTENDED MOVEMENT OF A SKYTRON SURGICAL TABLE MODEL 3600B OCCURRED IN AN OPERATING ROOM, WITH AN ANESTHETIZED PATIENT ON THE SURGICAL TABLE. THE SURGICAL TABLE MOVED UPWARD WITHOUT HAND CONTROL OR MANUAL ACTIVATION OF THE TABLE UP FUNCTION. PROBLEM: THE SKYTRON SURGICAL TABLE MOVED TO ITS MAXIMUM HEIGHT AND THEN STOPPED. THE OCCURRENCE WAS AFTER INDUCTION OF ANESTHESIA AND PRIOR TO INCISION/BEGINNING OF PROCEDURE. DATE OF OCCURRENCE-(B)(6) 2025. NO PATIENT INJURY: HOWEVER, THE PATIENT WAS AT SIGNIFICANT RISK FOR INJURY A SECOND EVENT OCCURRED, EXACT DATE UNKNOWN; HOWEVER, IT OCCURRED THE DAYS FOLLOWING (B)(6) 2025 AND REPORTED BY AN RN STAFF MEMBER WHO MOVED THE SURGICAL TABLE OUT OF THE CLINICAL AREA. AFTER POSITIONING THE SURGICAL TABLE IN A NON-PATIENT AREA, AN UNINTENDED MOVEMENT OF THE SURGICAL TABLE TO ITS MAXIMUM HEIGHT POSITION OCCURRED WITHOUT ACTIVATION BY THE HAND OR MANUAL CONTROL. PT CODE: 4582. DEVICE CODE: 1430. REFERENCE REPORT: MW5174134.