220 CART WASHER

Additional Manufacturer Narrative

A STERIS SERVICE TECHNICIAN ARRIVED ON SITE TO INSPECT THE UNIT. THE TECHNICIAN FOUND THE UNIT EXPERIENCED A CONTROL FAILURE AFTER THE STEAM INJECTION PHASE. THIS FAILURE CAUSED THE WASHER TO INDICATE THE CYCLE WAS COMPLETED, WHEN IN FACT, THE WASHER FAILED TO PERFORM THE LAST CYCLE, WHICH IS THE DRY PHASE. AS A RESULT, STEAM WAS PRESENT WHEN THE OPERATOR OPENED THE DOOR TO UNLOAD ITEMS. THE SPRINKLER SYSTEM DID INITIATE. THE SPRINKLER HEAD NEAR THE WASHER INITIATED, COVERING THE FLOOR SURROUNDING THE FRONT OF THE WASHER IN THE CLEAN SPD ROOM. HOSPITAL SECURITY RESPONDED TO THE EVENT; NO EMERGENCY SERVICES WERE CONTACTED. THE TECHNICIAN FOUND THE INTERMEDIARY PC CONTROL BOARD HAD CORROSION ON THE CIRCUITS. THIS WAS ATTRIBUTED TO PROLONGED EXPOSURE TO MOISTURE. THE TECHNICIAN REPLACED THE PC CONTROL BOARD AND PERFORMED A TEST CYCLE. THE UNIT WAS CONFIRMED OPERATIONAL AND RETURNED TO SERVICE.

Description of Event or Problem

THE USER FACILITY REPORTED THAT STEAM ESCAPED FROM THEIR 220 CART WASHER WHEN THE DOOR WAS OPENED AFTER A COMPLETED CYCLE. THE SPRINKLER SYSTEM INITIATED. NO PROCEDURAL DELAYS OR CANCELLATIONS HAVE BEEN REPORTED. NO INJURIES TO HOSPITAL STAFF OR PATIENTS WERE REPORTED.