OtherKPW
EIMAC-VARIAN
Received Nov 19, 1996 · Event occurred Nov 11, 1996
Report 51396 · MDR key 51396
Device
Generic name
Beam Limiting Device
Manufacturer
Elimac Varian (sold To: Fisher/machett)Model number
S 90968Catalog number
NA
Lot number
NA
Product problems
- Detachment Of Device Component
- Component Falling
- Installation error
Patient
49 YR
- Bruise/Contusion
- Headache
- Pain
Narrative
Description of Event or Problem
PT WAS LYING ON THE X-RAY TABLE HAVING X-RAY TAKEN OF HER MANDIBLE. THE EXTENSION CONE WAS ON THE MACHINE. A SINGLE AP FILM HAD BEEN TAKEN. THE MACHINE WAS BEING MOVED AWAY FROM THE PT TO TAKE ANOTHER VIEW. THE MACHINE WAS ANGLED AND THE CONE FELL FROM THE MACHINE STRIKING THE PT'S HEAD. CONE INSTALLED WRONG IN 1990; SIDE MOUNT INSTEAD OF FRONT MOUNT. NO SPRING LOCK INSTALLED. LAST INSPECTION 5/29/96.