Cause of Device-Related Incident
Device factors

Clinical Specialty or Hospital Department
Clinical/Biomedical Engineering; Facilities Engineering; Nursing

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

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Mechanical (puncture, perforate, lacerate, break, cut, tear, nick, crush)

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

UMDNS
Mounts, Television Set, Hospital [15-986]

Loose Screws in TV Mounts



Hazard [Health Devices Nov 1992;21(11):427]

Problem

A member hospital reported an incident in which a television set fell from its mounting bracket when a nurse attempted to swivel it. The TV struck the nurse on the shoulders and back, fell to the floor, and then shattered. It was subsequently discovered that the locking screw in the swivel that holds the TV tray to the wall bracket of the mount (see figure) had backed out. The locking screw is the only screw in the assembly that is in a circular hole; the other three screws are in keyhole-shaped holes (this is apparent only when the TV is dismounted). After the locking screw backed out, the three remaining screws in the assembly were then able to slip out of the keyhole slots in the swivel, allowing the TV to fall.

Manufacturer's comments

The particular device involved in this incident is no longer manufactured, but its design is similar to that of newer models. However, this is the only reported failure of this type of mount assembly. Proper tightening of the screws will prevent such a failure, and a thread locker can also be used during installation.

Discussion

Although the incidence of this problem is apparently low, the outcome could be severe. Hospitals typically have numerous TV mounts of various brands that are used by hospital staff, patients, and visitors. While not all mounts will be of the type or brand involved in this incident, the designs may be similar. TV mounts are rarely inspected, and problems with them are infrequently reported; however, other situations besides the one in this incident could be uncovered and corrected during an inspection. ECRI believes that, considering the risks, such preventive action should be taken.

Recommendations

  1. Inspect all TV mounts for security. Inspect the mounts to determine whether the screws holding the TV tray to the wall bracket are tight. Check that swivel bases are firmly attached to the wall mount bracket. Consider applying a penetrating thread locker (e.g., Loctite® Low Viscosity Threadlocker 290) to the protruding threads of the screws holding a swivel base to the wall mount; the thread locker will be pulled into the threads and prevent the screw from backing out during use.
  2. Contact ECRI concerning similar problems with TV mounts.

UMDNS Term

Mounts, Television Set, Hospital [15-986]

Cause of Device-Related Incident

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

Mechanism of Injury or Death

Mechanical


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