MICROTOME BLADES ARE EXTREMELY SHARP AND INHERENTLY DANGEROUS. INATTENTION TO THE TASK AT HAND AND FAILURE TO UTILIZE SAFETY DEVICES CAN CAUSE A SERIOUS INJURY. THE AUTOSECTION INSTRUMENT IS EQUIPPED WITH A RED COLORED BLA DDE GUARD AS A SAFETY DEVICE TO PROTECT THE USER FROM ACCIDENTAL EXPOSURE TO THE BLADE EDGE AND INJURY WHEN USED PROPERLY. BASED ON THE INFORMATION PROVIDED BY THE USER FACILITY, THE USER HAD RECEIVED ADEQUATE TRAINING, HOWEVER, FAILED TO VERIFY THE CALIBRATION STATUS ON THE SCREEN, AND BRING THE BLADE GUARD UP TO ITS POSITION WHEN REMOVING THE BLOCK FROM THE CHUCK WHICH WOULD HAVE PREVENTED THIS CUTTING INJURY. THE OPERATING MANUAL, SEC 1.4.1 AND 4.6, CLEARLY STATES THAT USER MUST "ALWAYS LOCK THE HAND WHEEL AND COVER THE CUTTING EDGE WITH THE BLADE GUARD PRIOR TO MANIPULATING THE BLADE OR THE SPECIMEN, CHANGING THE SPECIMEN, OR WHEN THE INSTRUMENT IS NOT IN USE." THE INSTRUMENT DID NOT MALFUNCTION OR CAUSE THIS INJURY; IT FUNCTIONED AS INTENDED ACCORDING TO THE SPECIFICATIONS AND IS SAFE TO USE.
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Patient 1
SAKURA RECEIVED A COMPLAINT THAT USER CUT HER FINGER WITH THE TISSUE-TEK AUTOSECTION INSTRUMENT, (B)(4). ON THE DATE OF THE EVENT, (B)(6) 2016, A USER CUT HER RIGHT THUMB WHILE PERFORMING A BLADE CALIBRATION WITH A NEW BLADE. SHE THOUGHT THE CALIBRATION WAS COMPLETED, TRIED TO REMOVE THE BLOCK BUT DID NOT USE THE BLADE GUARD TO COVER THE CUTTING EDGE, NOR DID SHE VERIFY THE BLADE CALIBRATION STATUS WITH THE AUTOSECTION SCREEN. THE BLADE MOVED UP AND CUT HER RIGHT THUMB. SHE WENT TO THE EMERGENCY ROOM AND RECEIVED SOME STITCHES.