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Patient 1
THE DEVICE IS A STATIONARY DIAGNOSTIC X-RAY SYSTEM WITH A MOTORIZED "C-ARM" TUBEHEAD/BUCKY ASSEMBLY. THE TECHNOLOGIST WAS PREPARING TO DO FOOT STUDY. THE TUBE WAS ROTATED TO POINT DOWN TO THE FLOOR. THE FIRST EXPOSURE WAS TAKEN. PREPARING TO MAKE A STANDING FOOT EXPOSURE, THE C-ARM WAS THEN ANGLED TO LESS THAN 90 DEGREES WITH THE TUBE POINTING TO THE FLOOR. THE TECHNOLOGIST ADJUSTED THE TUBE (SID) REDUCING THE DISTANCE BETWEEN THE TUBE AND THE BUCKY TO IMPROVE THE ALIGNMENT TO THE DIGITAL SENSOR. WHILE THE TUBE WAS MOVING, AN ERROR WAS DISPLAYED ON THE LED INDICATOR. THE TECH WAS NOT SURE OF THE ERROR CODE; MAYBE -31. AT THIS POINT, THE SYSTEM FROZE. THE TECH WAS UNABLE TO MAKE THE SYSTEM RESPOND. SHE REBOOTED THE SYSTEM. DURING THE BOOTING PROCESS THE LED DISPLAY FLASHED AN ERROR CODE WITH A LINE THROUGH IT. THE LCD DISPLAY HAD LINES THROUGH THE DISPLAY AND WAS ALSO FLASHING. TECH THEN TRIED TO MOVE THE CARRIAGE DOWN BY DEPRESSING THE DOWN BUTTON AT THE CONTROL PANEL BUT IT DID NOT RESPOND. SHE RELEASED THE DOWN BUTTON AND SUDDENLY THE CARRIAGE BEGAN TO MOVE DOWN SLOWLY. THE CARRIAGE CONTINUED TO MOVE DOWN TO THE FLOOR. THE STEEL CABLE BEGAN TO UNWIND AFTER THE CARRIAGE CAME INTO CONTACT WITH THE FLOOR. AFTER HEARING A NOISE FROM THE REAR OF THE UNIT THE TECH HIT THE EMERGENCY STOP BUTTON AND THE MOTION STOPPED.