MalfunctionLNS
STORZ MEDICAL
Received Nov 24, 2003 · Event occurred Nov 14, 2003
Report MW1030347 · MDR key 500906
Device
Generic name
Lithrotripsy Table
Manufacturer
Storz MedicalModel number
ACME TRANSFORMER GP TRANSFORMERCatalog number
T-1-81052
Lot number
*
Product problems
- Nonstandard Device
- Defective Component
- Electrical wires, defective
Patient
57 YR
- Electric Shock
- Surgical procedure aborted/stopped
Narrative
Description of Event or Problem
A LITHROTRIPSY WAS DISCOVERED TO HAVE A PROBLEM SO THE PROCEDURE WAS CANCELLED. A TECHNICIAN TOUCHED AN ANESTHESIA CART AND THE LITHROTRIPSY TABLE AT THE SAME TIME AND RECEIVED AN ELECTRICAL SHOCK. AN INVESTIGATION REVEALED THAT A VENDOR-MADE ADAPTOR CORD WAS IMPROPERLY WIRED (THE HOT (WHITE) WIRE WAS CONNECTED TO THE COMMON TERMINAL IN THE GROUND PLUG. THE GREEN/GROUND WIRE IN THE CORD WAS CONNECTED TO ONE OF THE 120V TERMINALS IN THE PLUG.