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Patient 1
THE FACILITY REPORTED THE CHEMICAL DELIVERY SYSTEM (CDS) DISPENSE CANISTERS WERE DISINTEGRATING/ ERODING. THE FACILITY STATED THE EROSION OF THE CANISTERS PRODUCED A CHALK-LIKE SUBSTANCE WHICH WAS UNABLE TO PASS THROUGH ALL OF THE WATER/AIR CHANNELS IN SOME OF THE SCOPES PROCESSED IN THE EPS UNIT. DUE TO THE PRESENCE OF THE CHALK-LIKE SUBSTANCE IN THE SCOPES, THE FACILITY REPROCESSED ALL SCOPES AND VERIFIED THAT THE UNITS WERE FREE FROM CHEMICALS PRIOR TO USE IN PATIENT PROCEDURES. A SERVICE TECHNICIAN ARRIVED AT THE USER FACILITY, INSPECTED THE RELIANCE EPS UNIT AND CONFIRMED THE CUSTOMER WAS USING THE CORRECT, COMPATIBLE STERIS HLD/DG DETERGENT WITH THE RELIANCE EPS. THE TECHNICIAN REVIEWED CYCLE PRINTOUTS FROM THE DAY AND STATED NO ALARMS OR ABORTS HAD OCCURRED. THE RELIANCE EPS OPERATOR MANUAL STATES, "4.3 POST-PROCESSING CHECKLIST: RELIANCE DRY CHEMISTRY CONTAINER AND RELIANCE CDS CHEMICAL DELIVERY SYSTEM VERIFIED FOR ABSENCE OF SOLID RESIDUE." THE TECHNICIAN REPLACED THE DISPENSE CANISTERS, TESTED THE UNIT FOR CORRECT OPERATION AND RETURNED THE UNIT TO SERVICE. THE DISPENSE CANISTERS WERE REQUESTED FOR FURTHER EVALUATION; HOWEVER AT THIS TIME THE CUSTOMER HAS STATED THAT THE CANISTERS ARE NOT AVAILABLE. FOLLOWING THE EVENT, THE FACILITY STATED THEIR SERVICE PROVIDER INDICATED THEY WERE AWARE OF THE ERODING ISSUE WITHIN THE RELIANCE EPS UNIT, HOWEVER DID NOT REPLACE THE CANISTERS WHEN THE ISSUE WAS OBSERVED. THE FACILITY'S SERVICE PROVIDERS HAVE SINCE BEEN INSTRUCTED TO REPLACE THE DISPENSE CANISTERS IMMEDIATELY SHOULD DISINTEGRATION/ERODING BE OBSERVED. NO FURTHER ISSUES HAVE BEEN REPORTED.