AC POWERED INSTRUMENT STAND - 777 WALL TRANSFORMER SET(INCLUDING OTOSCOPES, OPH

Description of Event or Problem

WHILE PATIENT WAS RECEIVING O2 FLOW THERAPY IN THE PICU, THE OTO-OPHTHALMOSCOPE DIAGNOSTIC SET'S PLUG IN AC POWER CONNECTOR SHORTED AND CAUSED AN ELECTRICAL FLASH AND SPARKS RESULTING IN DAMAGE TO THE CONNECTOR AND SURROUNDING AC OUTLET. THE PATIENT WAS DISCONNECTED FROM MONITORING AND O2 THERAPY AND EVACUATED FROM THE ROOM. THE CLINICIAN REMOVED THE POWER CONNECTOR FROM THE AC OUTLET AND NOTIFIED MANAGEMENT AND ENGINEERING. INVESTIGATION DETERMINED THAT FLUID FROM THE DISPOSABLE NEBULIZER HAD LEAKED ONTO THE AC POWER CONNECTOR AND CAUSED THE SHORT. BIOMEDICAL NOTED A POSSIBLE DESIGN FLAW IN THE CONNECTOR THAT WOULD ALLOW FLUID INTRUSION. BIOMEDICAL REMOVED THE DEVICE FROM PICU FOR REPORTING TO FDA MEDWATCH MAUDE DATABASE AND NOTIFICATION OF THE DEVICE MANUFACTURER. NO PATIENT HARM RESULTED FROM THIS EVENT.