SAFETY ACTION NOTICE
By arrangement with the NHS in Scotland, Management Executive
LIGHT BEAM DIAPHRAGMS ON X-RAY EQUIPMENT
RISK OF BECOMING DETACHED
SAN(SC)98/03
28 JAN 1998
Medical Devices
Page 1 of 1 Pages
SUMMARY
Incidents continue to be reported whereby x-ray light beam diaphragms become detached during use.
Advice is given on the steps that can be taken to reduce the likelihood of such incidences.
BACKGROUND
1. Incidents continue to be reported of light beam diaphragms (LBDs) becoming detached during use.
Such failures can be attributed to lack of care or maintenance and there is the potential for serious
injury.
2. Different manufacturers use different designs to attach the LBD to the x-ray tube. Some
manufacturers have additional safety features to prevent the tube becoming completely detached.
ACTION
3. This notice should be brought to the attention of all appropriate managers, staff and users.
4. The manufacturer’s instructions should be followed to ensure safe operation of LBDs.
5. LBDs should not be used to position tubes except where handles are specifically provided on the
LBD for this purpose or where the manufacturer instructs that the LBD may be used when moving
the tube into position.
6. The LBDs and any safety features to prevent them becoming detached should be checked during a
planned preventative maintenance service. Checks should be made more frequently on units where
the LBD might suffer excessive strain or in situations where the unit is more likely to be damaged
through impact. Particular attention should be paid to mobile equipment.
7. In addition, users should be aware of:
• the mechanism by which the light beam diaphragm is fitted to the x-ray tube housing and any
safety features that could prevent the LBD falling should it become detached;
• checks that should be carried out routinely to verify the correct attachment of the LBD;
• indications of an impending failure.
Suggested Distribution
Medical Physics
Device Managers
Radiology/Imaging
Estates/Facilities
Risk Management
General Dental Practitioners
Safety Officers
SCOTTISH HEALTHCARE SUPPLIES
Gyle Square Edinburgh EH12 9EB
A Division of the National Service Scotland for NHSScotland
This notice was obtained from the INCIDENT REPORTING & INVESTIGATION CENTRE (public) website
http://www.nhsscotland.com/shs/hazards_safety/adverse_p.html
FAX: 0131 314 0722
E-MAIL: [email protected]
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