[191782]
A procedure was being performed, for a pt, when the power to the x-ray equipment failed. The table drifted back to about a 20-30% angle and stopped. The tower began drifting downward, which required that the attending radiologist to manually support the weight of the tower to keep the tower from lowering onto the pt. All equipment controls were unresponsive. The pt was moved from the x-ray table. No injuries were reported, to the pt or staff. Rptr talked with the tech and learned that the malfunction actually could have created an injury had the radiologist not supported the weight of the tower until the pt was moved from the x-ray table. When the repair tech arrived, rptr spoke extensively with them in an attempt to learn about the mechanism that controls the tower. From the conversation, it appears that the fail-safe mechanism did not function properly. Also, if the table was in the flat position, the tower could drop to about six inches above the table, which would place the tower onto a pt. The repair tech did mention that this particular problem, referred above, should not have occurred based upon safeguards incorporated into the equipment. The equipment was repaired and placed back into svc. Rptr questions: why the fail-safe mechanism did not function properly and could this particular problem occur in the future. Corrective action: troubleshot spider gear, table tilt axis undemanded movement, k2 relay inactive due to safe circuit ordered pcb control. Recalibrate table tilt reference. Replaced table control pcb. Calibrate and tested.
Patient Sequence No: 1, Text Type: D, B5