HYDROCOLLATOR
Received Jun 19, 2014 · Event occurred Jun 17, 2014
Report MW5036773 · MDR key 3893655
Device
Product problems
- Thermal Decomposition of Device
- Charred
- Fire
- Device Emits Odor
- Overheating of Device
- Device Inoperable
Patient
Not reported
- No Consequences Or Impact To Patient
Narrative
Description of Event or Problem
ON (B)(6), STAFF IN PHYSICAL THERAPY REPORTED AN ELECTRICAL BURNING SMELL COMING FROM THEIR HOT PACK CONDITIONER. THE BIOMEDICAL EQUIPMENT TECH RESPONDED AND DID NOT FIND ANY PROBLEMS AT THE TIME, AND THE BURNING SMELL HAD DISSIPATED. THE NEXT MORNING (B)(6), IT WAS REPORTED THAT THE HOT PACK CONDITIONER WAS NOT WORKING. THE BMET REMOVED THE COVER OF THE HOT PACK CONDITIONER FOR TESTING AND REPAIR, AND DISCOVERED THAT THERE HAD BEEN A SMALL ELECTRICAL FIRE INSIDE OF THE DEVICE. TWO WIRES CONNECTING THE HEATING ELEMENT SHOW SIGNS OF HEATING/FIRE DAMAGE. THE TOP WIRE SHOWS BROWNING AND CHARRING WHERE IT CONNECTS TO THE HEATING ELEMENT. THE BOTTOM WIRE HAS BEEN BURNED THROUGH AND IS COMPLETELY SEVERED. NEITHER OF THE TWO 15-AMP FUSES IN THE ELECTRICAL CONNECTION BLEW. PICTURES WERE TAKEN AT THE TIME OF DISCOVERY AND ARE AVAILABLE. NO PT HARM OCCURRED, AND THE FIRE WAS CONTAINED TO THE HOT PACK CONDITIONER.