Cause of Device-Related Incident
Device factors; User errors

Clinical Specialty or Hospital Department
Clinical Laboratory; Clinical/Biomedical Engineering; Infection Control

Device Factors
Design / labeling error; Device failure; Improper maintenance, testing, repair, or lack or failure of incoming inspection; Manufacturing 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; Incorrect clinical use

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

Centrifuges



Hazard Report Summary [Health Devices Apr 1995;24(4):158-9]

Problem

We have received numerous reports from member hospitals of exposure to bloodborne pathogens from blood and glass sprayed from beneath the lid of centrifuges. Since the time of publication of our Hazard Report Summary, "Centrifuges," in Health Devices 21(12), December 1992, we continue to receive numerous requests for information concerning the safety of and purchasing considerations for centrifuges.

Recommendations

Use the following safety measures to avoid problems similar to those reported:

Safety Features for Centrifuges

  • Lids: Discontinue use of any centrifuge that does not have a lid and do not retrofit the unit with a lid that does not have a latch.
  • Latches: Discontinue use of any centrifuge that does not have a latch; the latch keeps the centrifuge lid closed in the event of tube breakage or other problems while the centrifuge is operating. All such units should be replaced or modified to include a latch; contact the manufacturer for information.
  • Interlocks: If available, purchase centrifuges that have lids with interlocks to prevent the user from opening the lid while the rotor is spinning.
  • Inner safety lids: When possible, purchase centrifuges that have inner safety lids for the buckets or rotor. If the units being purchased allow the outer lid to be opened while the rotor is spinning at low speeds, be sure they have protective inner lids.

Proper Use of Centrifuges

  • Ensure that the centrifuge tubes are properly balanced and that the speed and tube length are in accordance with the tube and the centrifuge manufacturer's recommendations. Do not use tubes that are not properly sized for the rotor. If using a swinging-bucket rotor, ensure that the tubes are placed in accordance with the manufacturer's instructions; long tubes (e.g., greater than 100 mm) placed in the corner tube holders closest to the rotor shaft may break when the rotor buckets swing out.
  • For centrifuges with swinging-bucket rotors, fasten a protective inner safety lid (if available for your model centrifuge) onto the bucket; for those with fixed-angle rotors, fasten an inner safety lid to the rotor before centrifugation. Ensure that the safety lid is properly sealed and positively locked into place.
  • Ensure that the rotor has completely stopped spinning before opening the lid, even if an "OPEN LID" indicator lights and the safety interlock disengages. 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.
  • NEVER attempt to stop a moving rotor with your hands or with a tool or object (e.g., a paper towel).
  • All personnel should follow universal precautions when performing centrifugation and other functions that may expose workers to splashed blood or body fluids. These precautions include wearing gloves, facial protection (e.g., shields), gowns or laboratory coats, and plastic aprons; these are described in detail in the National Committee for Clinical Laboratory Standards' (NCCLS) tentative guideline(1) and the Occupational Safety and Health Administration's (OSHA) bloodborne pathogens standard.(2)

Maintenance Procedures for Centrifuges

  • During preventive maintenance, ensure that the nut that secures the rotor to the shaft is tight (check the manufacturer's instructions).
  • Clean and disinfect all centrifuges regularly according to the manufacturer's recommendations. Contact the manufacturer for guidance if the operator's manual does not specify cleaning or disinfecting agents. Prolonged contact with some disinfectants (e.g., 10% sodium hypochlorite) may damage the rotor and other centrifuge components; be sure that such solutions are removed by rinsing well with water.

In addition to the above, see the updated Procedure in Health Devices Inspection and Preventive Maintenance System.

ECRI Resources

From Health Devices

Centrifuges [Hazard Report Summary]. 1992 Dec;21(12):459-60.

Dislodging of rotor and improper sealing of cover lids on Baxter Medifuge C1700-2 centrifuges [Hazard Report]. 1992 Oct;21(10):380-1.

Improper sealing of Baxter Megafuge C1725-2 centrifuges [Hazard Report]. 1992 Sep;21(9):331-2.

Risks from centrifuges [Hazard Update]. 1992 Aug;21(8):290-1.

Missing roll pin from Beckman Spinchron centrifuge rotor [User Experience Network]. 1992 May;21(5):182-3.

Risks from Baxter Multifuge and other centrifuges without safety latches [Hazard Report]. 1991 Jan;20(1):29-30.

Risk of cross contamination [Perspective]. 1989 Oct;18(10):331-2.

Operator safety. 1989 Jul-Aug;18(7-8):279.

From ECRI's Health Devices Inspection and Preventive Maintenance (IPM) System

IPM Procedure for centrifuges. 1995 May; Procedure/Checklist No. 456-0595.

Notes

  1. National Committee for Clinical Laboratroy Standards (NCCLS). Protection of laboratory workers form infectious disease transmitted by blood, body fluids, and tissue. 2nd ed. (tentative guideline). Villanova, PA: NCCLS, 1991 Sep (NCCLS Document M29-T2). This document can be obtained from NCCLS. 771 E. Lancaster Ave., Villanova, PA 19085; (610) 525-4383.
  2. Occupational Safety and Health Administration (OSHA). Occupational exposure to bloodborne pathogens; final rule 29 C.F.R. Sec. 1910.1030. Fed Regist 1991 Dec 6;56(235):64004-182.

UMDNS Terms

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

Cause of Device-Related Incident

Device factors: Design/labeling error; Device failure; Improper maintenance, testing, repair, or lack or failure of incoming inspection; Manufacturing error

User errors: Inappropriate reliance on an automated feature; Incorrect clinical use

Mechanism of Injury or Death

Exposure to airborne infectious agents; Exposure to bloodborne pathogens; Mechanical


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