EVOLUTION TRANSFER CARRIAGE

Description of Event or Problem

THE USER FACILITY REPORTED THAT WHILE AN EMPLOYEE WAS UNLOADING THEIR STERILIZER, THEIR EVOLUTION TRANSFER CARRIAGE BECAME UNSTABLE AND THE INSTRUMENT RACK FELL TO THE FLOOR. NO REPORT OF INJURY.

Additional Manufacturer Narrative

A STERIS SERVICE TECHNICIAN ARRIVED ONSITE FOLLOWING THE REPORTED EVENT TO INSPECT THE UNIT. THE TECHNICIAN FOUND THAT THE LOADING CAR, LOADING CAR RACK, TRANSFER CARRIAGE, AND STERILIZER DOCKING STATION WERE DAMAGED AS A RESULT OF THE REPORTED EVENT. BASED ON THE DESCRIPTION OF THE EVENT AND THE TECHNICIAN'S INSPECTION, IT IS LIKELY THAT THE TRANSFER CARRIAGE'S FRONT WHEEL ASSEMBLY HAD NOT BEEN PROPERLY LOCKED TO THE STERILIZER'S DOCKING STATION RESULTING IN THE REPORTED EVENT. TO RESOLVE THE ISSUE, THE TECHNICIAN REPLACED THE LOADING CAR, LOADING CAR RACK, TRANSFER CARRIAGE, AND STERILIZER DOCKING STATION. THE UNITS WERE TESTED, CONFIRMED TO BE OPERATING ACCORDING TO SPECIFICATION, AND RETURNED TO SERVICE. THE TECHNICIAN COUNSELED FACILITY PERSONNEL ON THE PROPER USE AND OPERATION OF THE TRANSFER CARRIAGE, SPECIFICALLY ENSURING THAT THE FRONT WHEEL ASSEMBLY IS PROPERLY LOCKED TO THE STERILIZER'S DOCKING STATION. NO ADDITIONAL ISSUES HAVE BEEN REPORTED.