[3024126]
Gi technician noted clear liquid coming out of a processed endoscope. This tech then noted that two bulkhead connectors were not allowing flow. Bay was taken out of service. Hospital? S biomed staff was able to correct this by replacing swollen o-rings. Both connectors were then replaced by oem? S service rep on (b)(6) 2012. Flow from all connectors was verified by hospital biomed staff during a pm on (b)(6) 2012. When the oem service rep was first contacted on (b)(6), he was asked why this condition did not generate an alarm as that is what was expected according to the info the staff was given by the company. The service rep assured gi personnel that any bulkhead connector that had obstructed flow would generate alarms. A teleconference on (b)(6) 2012 with oem clarified that there is no flow obstruction alarm for individual bulkhead connectors on this system. The oem service rep that was on site on (b)(6), recommended to start a process to routinely check the flow of each channel/bulkhead. This is new instruction from the company and was not taught to hospital staff during custom ultrasonics? Installation in-services. It was also noted during the (b)(6) 2012 teleconference that custom ultrasonics does not have a process for updating operator and service manuals that are in use and ensuring their customers are following the latest operational and service guidance. Bay was placed back into service.
Patient Sequence No: 1, Text Type: D, B5