inforMED
MalfunctionFLE

NA

Received Dec 18, 2025 · Event occurred Nov 18, 2025

Report 3005899764-2025-00100 · MDR key 23843486

Device

Generic name

Atlas Transfer Carriage

Model number

AX083020003

Catalog number

AX083020003

Product problems

  • Unintended Movement
  • Unintended Movement

Patient

NA · Unknown

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

Narrative

Additional Manufacturer Narrative

TO RESOLVE THE ISSUE, THE TECHNICIAN REPLACED THE CART AND REPAIRED THE DOCKING STATION. THE UNIT WAS TESTED, CONFIRMED TO BE OPERATING ACCORDING TO SPECIFICATION, AND RETURNED TO SERVICE. A STERIS ACCOUNT MANAGER PROVIDED IN-SERVICE TRAINING ON THE PROPER USE AND OPERATION OF THE EVOLUTION TRANSFER CARRIAGE, SPECIFICALLY ON PROPERLY LATCHING THE CARRIAGE TO THE DOCKING STATION. NO ADDITIONAL ISSUES HAVE BEEN REPORTED.

Additional Manufacturer Narrative

A STERIS SERVICE TECHNICIAN ARRIVED ONSITE FOLLOWING THE REPORTED EVENT TO INSPECT THE UNIT AND FOUND THAT THE DOCKING STATION, TRANSFER CARRIAGE AND THE LOADING CAR 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. THE CARRIAGE SUBJECT OF THE REPORTED EVENT IS PENDING REPAIRS. A FOLLOW-UP REPORT WILL BE SUBMITTED ONCE ADDITIONAL INFORMATION BECOMES AVAILABLE.

Description of Event or Problem

THE USER FACILITY REPORTED THAT THEIR EVOLUTION TRANSFER CARRIAGE FELL TO THE FLOOR WHILE AN EMPLOYEE WAS UNLOADING THE STERILIZER. NO REPORT OF INJURY.