[2749]
Nurse lincoln had just returned from transporting an infant patient to nicu, and she plugged the empty unit in to recharge. A few minutes later smoke was discovered coming from the warmer. Upon inspection, it was discovered that flames were in evidence under the patient platform. The flames were subsequently extinguished with a co2 extinguisher. Once the flames were extinguished the transport incubator was turned over to cbet, of biomedical instrumentation. The following observations were made by biomedical instrumentation who inspected and evaluated the transport incubator. (see attached report). Device not labeled for single use. Patient medical status prior to event: invalid data. Invalid data - regarding multiple patient involvement. Device serviced in accordance with service schedule. Date last serviced: 01-dec-92. Service provided by: user facility biomedical/bioengineering department. Invalid data - service records availability. Imminent hazard to public health claimed. Device used as labeled/intended. Device was evaluated after the event. Method of evaluation: actual device involved in incident was evaluated, electrical tests performed, mechanical tests performed, visual examination. Results of evaluation: component failure, electric problem - short circuit, insulation degradation/deterioration, material degradation/deterioration. Conclusion: device failure occurred and was related to event, device failure directly caused event. Certainty of device as cause of or contributor to event: yes. Corrective actions: device temporarily removed from service, use of all similar devices stopped temporarily, inserviced by biomedical engineering dept. Staff. Invalid data - on device destroyed/disposed of status.
Patient Sequence No: 1, Text Type: D, B5