Cause of Device-Related Incident
Device factors; User errors

Clinical Specialty or Hospital Department
Clinical Laboratory; Clinical/Biomedical Engineering; Pharmacy / IV therapy

Device Factors
Design / labeling error

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Exposure to airborne infectious agents; Exposure to bloodborne pathogens

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
Inappropriate reliance on an automated feature

UMDNS
Centrifuges [10-778]; Centrifuges, Tabletop [10-780]

Risks from Centrifuges



Hazard Update [Health Devices Aug 1992;21(8):290-1]

Problem

In Health Devices 20(1), Jan 1991, we published a Hazard Report on centrifuges without safety interlock latches on their cover lids. In one incident, blood products and glass were sprayed from beneath the centrifuge lid onto the chest of a medical technologist. Although no injury was incurred, the technologist was exposed to an infection risk. We recommended that all centrifuges have safety interlocks to avoid exposure to spinning rotors and blood or body fluid tubes. Since our previous report was published, we have learned that some centrifuges with latch interlocks allow the lid to be opened before the rotor has completely stopped. According to Section 7.2.101 of the International Electrotechnical Commission (IEC) Draft Standard 66E (Central Office) 11, Safety Requirements for Electrical Equipment for Measurement, Control, and Laboratory Use—Part 2-2: Particular Requirements for Laboratory Centrifuges (to be used in conjunction with IEC 1010-1), it should not be possible to open the rotor assembly access lid until the circumferential velocity is 2 m/sec or less. This limit can be converted to revolutions per minute (rpm) for a specific centrifuge rotor with the following equation:

rpm = (v/2 pi r) x 60

where

v = velocity of the rotor in meters/second (2 m/sec limit in draft standard)

r = radius of the rotor in meters

For example, under the requirements of the IEC draft standard, the lid of a centrifuge with a rotor radius of 19 cm would be permitted to be opened at 100 rpm. Although this low speed will help to minimize the risk of injury, we prefer that the centrifuge have a latching mechanism that prevents the lid from opening until the rotor is completely stopped and/or that it have a sealed rotor or a rotor with sealed carriers.

Recommendations

  1. To avoid infection and physical risks, inform operators not to open the lid of any centrifuge until the rotor has stopped, even if an "open lid" indicator lights and the latch has disengaged. However, in some cases, the rotor may not be visible; therefore, the user should allow a reasonable amount of time for the rotor to stop and should feel the top of the lid for the cessation of vibration before opening it. Users should never try to slow down or stop the centrifuge rotor by hand.
  2. Do not purchase centrifuges with lids that can be opened while spinning at high speed. ECRI recommends purchasing only those units on which the rotor stops completely before the lid can be opened and/or, for units that spin at a low speed, those that have a sealed rotor or sealed carriers (totally sealed rotors or sealed carriers are recommended for all centrifuges if available for specific models).
  3. Discontinue using centrifuges that lack a safety latch. All such units should be replaced or modified.
  4. All personnel should follow universal precautions when performing centrifugation and other functions that may expose workers to splashed blood or body fluids. (Also see the following: 1) Health Devices 18[7-8], Jul-Aug 1989;18[10], Oct 1989; and 20[1], Jan 1991. 2) C.F.R § 1910.1030. Occupational Safety and Health Administration [OSHA]. "Occupational Exposure to Bloodborne Pathogens, Final Rule." Fed Regist 1991 Dec 6;56[235]:64004-182. 3) Procedure for centrifuges. Health Devices Inspection and Preventive Maintenance System.)

UMDNS Terms

  • Centrifuges [10-778]
  • Centrifuges, Tabletop [10-780]

Cause of Device-Related Incident

Device factor: Design/labeling error

User error: Inappropriate reliance on an automated feature

Mechanism of Injury or Death

Exposure to airborne infectious agents; Exposure to bloodborne pathogens


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