A surgical lamp fell from the ceiling at United Hospital, crushing the shoulder of an anesthesia assistant.
The Hospital Authority announced the preliminary results of the investigation today (24th). The expert consultant appointed by the Bureau, Lin Chaoxiong, said that all six screws of the surgical lamp involved in the incident were broken, showing the unique "beach pattern" (also called fatigue streaks) of metal fatigue cracks. The starting point of the screw is also rusted, and it was discovered within a short period of time that the material fatigue pattern has existed for a year and a half.
Lin Chaoxiong believes that if maintenance personnel test with a torque wrench of appropriate strength, they should be able to find cracks.
As for other problematic surgical lights, Lin said that he found looseness, disconnection, etc., and some screws even appeared "slip teeth".
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Manufacturers use high-quality screws that are properly maintained and have a longer lifespan
After investigating the surgical lamp involved, Lin Chaoxiong said that the manufacturer used high-quality screws equipped with screw glue in the design, so that it will be easy to move during the operation. Generally speaking, these screws are more resistant to metal fatigue. If they are properly maintained Long life.
However, he said that he noticed that all 6 screws of the surgical lamp involved were disconnected, and there were typical "beach patterns" (or "shell patterns") that would occur when metal fatigue ruptures.
He said that the screws of the surgical lamp began to appear these fatigue cracks under long-term constant vibration, and slowly grew after a period of time, and would break when they could no longer bear the force.
Maintenance personnel should be able to find cracks if they have tested and inspected
He also said that he noticed that although the surface of the part where the screw was disconnected was clean, the starting point began to rust. Considering that the environment in the operating room is good and the temperature and humidity are kept at an appropriate level, he also said that it will take a long time for rust to occur. The crack has been there for a year and a half.
He said that even if no cracks can be seen on the surface, if the maintenance personnel have a torque wrench to test, the screws will break, so they should be able to find cracks during the inspection. .
Some screws of other operating lights are loose, broken or "slipped teeth"
Lin also inspected the screws of other faulty operating lights, saying that some of the screws were loose or broken, and the loose screws were removed for inspection and found to have metal fatigue cracks.
He pointed out that more importantly, he found that the screw was "slipped". He suspected that someone had not aligned the twist properly and forcibly twisted the screw in.
He also said that he noticed that the entire design required rigorous maintenance, and maintenance personnel had to undergo in-factory training. "Three people may get a license on site, and only that person can do it."
As for how to avoid accidents, Lin Chaoxiong suggested that the screws should be replaced regularly within a reasonable period of use; he also suggested that if the screws are found to be loose in the future, they should be replaced as soon as possible by qualified personnel instead of tightening, because the screw glue may have expired when it is loosened , so new screws need to be replaced, and when checking the screws, it is also necessary to pay attention to whether the torque wrench is properly adjusted.
Surgical lights fell | Manufacturers did not report screw loss in the U.S. Last year, the Hospital Authority expressed regret for United Hospital surgical lights | Social Association pointed out that the United States had lost screws at the end of last year. The report urged the Hospital Authority to explain that the operating lights fell | Hospital Authority found 4 more There are risks in the chandelier screws. The 2nd operating room of the Zhongda Hospital stopped using the fallen operating lamp of the United Hospital.