D
Patient 1
THE ABBOTT VP 2000 PROCESSOR IS A DEVICE DESIGNED TO AUTOMATE AND STANDARDIZE SLIDE SPECIMEN PROCESSING AND ROUTINE SLIDE STAINING FOR THE LABORATORY. CUSTOMER WAS RUNNING UROVYSION PROTOCOL AND NOTICED THAT BASIN WITH THE PROTEASE HEATED UP TO 69 DEGREES C WHEN THE PROGRAM WAS SET TO 37 DEGREES C. CUSTOMER STOPPED THE VP2000 INSTRUMENT AND REBOOTED. TO TROUBLESHOOT THE VP2000 CUSTOMER FILLED THE HEATED BASINS WITH WATER AND STARTED THE INSTRUMENT WITH THE SAME PROTOCOL. THE INSTRUMENT HEATED UNEXPECTEDLY AND CUSTOMER NOTICED SMOKE BURNING OUT OF THE HEATER MODULE VP2000. CUSTOMER TURNED OFF THE VP2000. CUSTOMER STATED THAT THE VP2000 HEATED BASIN TEMPERATURES WERE NOT BEING CONTROLLED PROPERLY, AND THAT A SMALL AMOUNT OF SMOKE WAS OBSERVED NEAR HEATER BOX #3. FIELD SERVICE NOTED THAT THERE WAS DRIED AND CRYSTALLIZED REAGENT UNDER HEATER BOX #1, AND THAT THIS REAGENT HAD SLOWLY ADVANCED TO THE HEATER MODULE ASSY. CONTROL BOARD ((B)(4)). DAMAGE WAS OBSERVED ON THE HEATER MODULE ASSEMBLY, CONTROL BOARD AROUND THE HEATER BOX POWER CONNECTORS, AND IT WAS DETERMINED THAT THE CRYSTALLIZED REAGENT HAD "SHORTED" THE HEATER BOX POWER CONNECTIONS. THE CIRCUIT BREAKER (INSTRUMENT ON/OFF SWITCH) WAS FOUND IN THE "OFF" POSITION, INDICATING THAT THE CIRCUIT BREAKER TRIPPED WHEN THE SHORT OCCURRED. FIELD SERVICE REPLACED THE HEATER MODULE ASSEMBLY TO RESOLVE THIS ISSUE. NO INJURY WAS REPORTED.