inforMED
MalfunctionILJ

MALIBU/SOVEREIGN

Received Oct 10, 2018 · Event occurred Sep 21, 2018

Report 3007420694-2018-00196 · MDR key 7951287

Device

Generic name

Bath, Hydro-massage

Model number

AZL33216-GB

Product problems

  • Unintended Electrical Shock
  • Unintended Electrical Shock

Patient

Not reported

  • Electric Shock
  • No Patient Involvement
  • Electric Shock
  • No Patient Involvement

Narrative

Additional Manufacturer Narrative

THIS REPORT IS BEING FILED UNDER EXEMPTION E2012070 BY ARJOHUNTLEIGH POLSKA SP. Z O.O. (REGISTRATION#3007420694) ON BEHALF OF THE IMPORTER ARJOHUNTLEIGH, INC. (AHUS) (REGISTRATION#1419652). PLEASE NOTE THAT PREVIOUS MEDWATCH REPORTS FOR THIS PRODUCT MAY HAVE BEEN SUBMITTED FOR THE MANUFACTURING SITE ARJO HOSPITAL EQUIPMENT AB (UNDER REGISTRATION #9611530). AS OF 2014 THAT NUMBER WAS DE-ACTIVATED DUE TO THE SITE NO LONGER BEING A MANUFACTURER AND SHIPPING PRODUCT TO THE USA. FROM 2014 AND GOING FORWARD COMPLAINTS RELATED TO THESE PRODUCTS ARE TO BE HANDLED BY ARJOHUNTLEIGH AB'S COMPLAINT HANDLING ESTABLISHMENT AND ANY MEDWATCH REPORTS WILL BE SUBMITTED UNDER REGISTRATION #3007420694. THE COLLECTED INFORMATION IS UNDER FURTHER REVIEW. ADDITIONAL INFORMATION WILL BE PROVIDED WITHIN THE NEXT REPORT.

Description of Event or Problem

IT WAS REPORTED THAT NURSE RECEIVED AN ELECTRIC SHOCK FROM THE LIFT ARM, WHEN TRYING TO MOVE IT MANUALLY. NO PATIENT WAS INVOLVED. THERE IS NO INDICATION OF ANY INJURY OR MEDICAL TREATMENT. THE DEVICE WAS TAKEN OUT OF USE AND INSPECTED BY ARJO REPRESENTATIVE. THE FAULT COULD HAVE NOT BEEN REPLICATED. THE BATH WAS TESTED FOR AN ELECTRICAL SAFETY ON ALL METAL PARTS AND IT PASSED ALL TESTS. IT WAS SUSPECTED THAT THIS WAS A STATIC ELECTRIC SHOCK.

Additional Manufacturer Narrative

ARJO WAS NOTIFIED ABOUT AN EVENT WITH INVOLVEMENT OF THE MALIBU/SOVEREIGN BATHTUB. IT WAS REPORTED THAT NURSE RECEIVED AN ELECTRIC SHOCK FROM THE LIFT ARM (FOR THE BATH'S OWN CHAIR), WHEN TRYING TO MOVE IT MANUALLY. NO PATIENT WAS INVOLVED. THERE IS NO INDICATION OF ANY INJURY OR APPLIED MEDICAL TREATMENT. THE DEVICE WAS TAKEN OUT OF USE AND INSPECTED BY ARJO QUALIFIED PERSONNEL, BUT THE FAULT COULD HAVE NOT BEEN REPLICATED. THE BATH WAS TESTED FOR AN ELECTRICAL SAFETY ON ALL METAL PARTS AND IT PASSED ALL TESTS. NO FURTHER ACTION WAS NECESSARY. ACCORDING TO THE INSPECTION RESULTS, WHICH DID NOT REVEAL ANY ELECTRICAL MALFUNCTION, IT WAS SUSPECTED THAT THE REPORTED EVENT WAS A STATIC ELECTRIC SHOCK. THE REVIEW OF REPORTABLE EVENTS WITH THE INVOLVEMENT OF THE MALIBU/SOVEREIGN BATHTUB IN LAST YEARS REVEALED LOW NUMBER OF SIMILAR INCIDENT. BASED ON DEVICE'S EVALUATION (INCLUDING ELECTRICAL TEST) THERE WAS NO MALFUNCTION THAT COULD HAVE CAUSED OR CONTRIBUTED TO THE ALLEGED INCIDENT. IT WAS ALSO NOT POSSIBLE TO REPLICATE THE FAILURE REPORTED TO ARJO. THEREFORE IT IS SUSPECTED THAT WHEN THE NURSE TOUCHED THE METAL LIFTING ARM, HE EXPERIENCED A SHOCK CAUSED BY THE ELECTROSTATIC DISCHARGE. PLEASE NOTE THAT DESIGN OF THE MALIBU/SOVEREIGN ISOLATION SYSTEM BETWEEN APPLIED PARTS AND ELECTRICAL PARTS WAS TESTED FOR THE REQUIREMENTS OF THE SAFETY STANDARD IEC 60601-1 AND WAS CONFIRMED TO BE COMPLIANT. THE CLAIMED BATH IS EQUIPPED WITH THE TYPE B APPLIED PART PROTECTION AGAINST ELECTRICAL SHOCK IN ACCORDANCE WITH IEC 60601. IT SHOULD BE ALSO UNDERLINED THAT MAINTENANCE AND REPAIR MANUAL FOR THIS BATHTUB (09.AZ.01/0GB DATED ON MAY 2008) INCLUDES REQUIREMENTS TO CHECK ALL ELECTRICAL CABLING AND THE EARTH WIRING CONNECTIONS. IN SUMMARY, BASED ON THE REPORTED INFORMATION THE NURSE SUSTAINED AN ELECTRIC SHOCK, WHEN TOUCHED THE BATHTUB'S LIFTING ARM. THE BATHTUB WAS NOT USED FOR PATIENT HYGIENE AT THE TIME OF EVENT. ACCORDING TO THE DEVICE'S EVALUATION RESULTS IT MET THE MANUFACTURER'S SPECIFICATION. THIS COMPLAINT WAS DECIDED TO BE REPORTED TO THE COMPETENT AUTHORITIES BASED ON THE CUSTOMER ALLEGATION THAT THE ELECTRIC SHOCK OCCURRED.