Executive Summary

Overzealous or improper cleaning of electrical equipment can result in equipment malfunction, damage, or fire. Medical devices and other electrical equipment used in healthcare facilities must be cleaned and disinfected to prevent cross-contamination between patients and curtail the spread of infectious organisms. However, some cleaning practices can present risks.

The use of cleaning or disinfectant wipes that are dripping with excess fluid, or spraying liquids directly onto powered medical devices and equipment, can cause fluid to enter electrical components such as plugs, sockets, or power supplies. Repeated fluid ingress, and the residue it leaves behind, can create errant current pathways around the electrical component. These additional currents can eventually generate sufficient heat to cause a device failure, or worse.

ECRI is aware of multiple instances in which cleaning fluid seeping into electrical components has led to equipment damage or fire. Incidents have involved infusion pumps, OR tables, infant warmers, and electrical equipment such as light switches and power supplies.

When cleaning electrical equipment, staff should follow manufacturer instructions, they should avoid spraying fluids directly onto the equipment, and they should use appropriate cloths, wipes, and sponges (squeezing out excess liquid before use).

Who Should Read This

Table of Contents

See the full 2019 list of Top 10 Health Technology Hazards

 

Problem

1. Medical devices and other electrical equipment used in healthcare facilities must be cleaned and disinfected to prevent cross-contamination between patients and curtail the spread of infectious organisms. However, overzealous or improper cleaning can present risks.

2. Using cleaning or disinfectant wipes that are dripping with excess fluid, or spraying liquids directly onto powered medical devices and equipment, can cause fluid ingress in electrical components (e.g., plugs, sockets, wiring) that may result in equipment damage or fires.

a) Repeated fluid ingress in or around electrical components can create errant current pathways (i.e., arc tracking) around the electrical component. The errant current can generate heat and degrade the insulating material (Campbell and Howell 1998, NFPA 2017).

b) ECRI is aware of multiple instances in which the ingress of cleaning fluid into electrical components has led to equipment damage or fire. Incidents have involved devices such as infusion pumps, OR tables, and infant warmers, as well as electrical equipment such as light switches and power supplies.

3. Potential consequences of this problem include:

a) Electrical fire within a care area, requiring an emergency response

b) Delay of care caused by unexpected and prolonged downtime of equipment or rooms

c) The need to repair or replace damaged medical devices or electrical equipment

 

ECRI Recommendations

To reduce the risks of equipment damage and fires from cleaner and disinfectant fluid ingress in electrical medical devices and equipment, ECRI recommends the following:

1. Review the instructions for use of medical devices and equipment to identify the manufacturers' recommended cleaning and disinfection methods. If needed, add this information to relevant environmental services (EVS) checklists (i.e., those for use while a room is occupied and those for use after a patient is discharged).

2. Communicate the following recommendations to all staff who perform cleaning and disinfection. If needed, add these points to relevant EVS checklists:

a) Use appropriate cleaning and disinfecting cloths, wipes, and sponges.

b) Do not spray fluid directly onto electrical medical devices or other electrical equipment such as light switches, power receptacles, and plug sockets. Instead, spray fluid onto the cloth, wipe, or sponge, if needed.

c) Verify that fluid is not dripping from the cloth, wipe, or sponge before cleaning and disinfecting electrical devices and equipment. Squeeze out excess liquid until it does not drip.

d) Use extra care when applying fluids to any electrical equipment that is not specifically rated to withstand liquid ingress.

(1) Some devices are rated with an ingress protection (IP) code that indicates the extent to which the device resists intrusion, including by liquids (e.g., water). The code consists of the letters "IP" followed by two integers; the first refers to the level of protection against solids, while the second refers to the level of protection against liquids. The higher the number, the greater the level of protection.

(2) A rating of IPx4 or higher (where x is an integer specifying the level of protection against solids) indicates that the device is protected from water splashed from any direction. A number higher than 4 indicates that the device is even more resistant to water ingress.

(3) Exercise caution during cleaning and disinfection if a device is rated below this level or if the IP rating is unknown.

3. Conduct training of all staff who work with fluids around electrical medical devices and equipment, including EVS/housekeeping, nursing, and respiratory therapy personnel. Staff training should be conducted at least annually and be regularly reinforced through staff communication (e.g., during staff meetings).

4. If fluid ingress in electrical medical devices or equipment is observed:

a) Tag affected equipment for inspection by clinical/biomedical engineering.

b) Notify clinical/biomedical engineering that fluid ingress occurred.

c) Notify management in EVS/housekeeping, nursing, and respiratory therapy to provide feedback to their staff to try to prevent fluid ingress recurrence in electrical components of medical devices and equipment.

5. Refer to the Supplementary Materials tab for additional resources to help reduce the risks of this problem in your facility. See in particular our guidance article How Improper Cleaning Can Damage Medical Equipment, as well as Hazard No. 5 from last year's list of the Top 10 Health Technology Hazards.

 

Background

1. ECRI discussed this problem in a June 2018 Hazard Report distributed through Health Devices Alerts. By also including the topic on our Top 10 Health Technology Hazards list, we are encouraging all healthcare facilities to examine the risks associated with improper cleaning practices.

a) While diligent cleaning of medical devices and equipment is essential for patient safety, it can lead to equipment malfunction, damage, or fire if not done properly.

b) Our recommendations here are consistent with those published in the original Hazard Report, which additionally included perspectives from several medical device manufacturers.

2. How the problem occurs:

a) With each cycle of electrical component wetting from fluid ingress, conductive salts are left behind, increasing the errant current pathways for the next cycle. 

b) Eventually, the generated heat from errant current may be sufficient to char the insulation.

c) This combination of alternate conductive pathways (salts and char) can cause increased current (and heat) through the char, leading to:

(1) The interruption of power to the circuit by a fuse, breaker, or ground-fault circuit interrupter, or

(2) An electrical fire due to significant resistive heating, insulation material and conductors melting or breaking down, or arcing through broken conductors

3. Following are a few examples of incidents that ECRI has investigated or reviewed:

a) In August 2017, ECRI received a report from a facility that "the headwall unit of a patient bed had a light switch catch fire and melt."

(1) An EVS staff member had just finished cleaning the headwall and the light switch when smoke and flame were noticed coming from the light switch. The staff member discharged a portable fire extinguisher on the burning device.

(2) Subsequent testing discovered that moisture was present within another room's light switch after the same EVS staff member completed room cleaning.

(3) The facility reports that, as a result of the investigation, "EVS has adjusted their cleaning process to a less wet disinfectant."

b) The same facility provided a report of failed light switches in their facility between 2009 and 2017.

(1) Two reports of electrical fires in light switches

(2) Two reports of a person receiving an electric shock when turning on a light

(3) Five reports of visible sparking from light switches

c) In August 2017, ECRI received a report of an electrical fire in an infant warmer likely caused by fluid ingress in the detachable power cord socket.

d) In a December 2016 Hazard Report published in Health Devices Alerts, ECRI reported that fluid ingress in the electrical receptacle of OR tables can cause electrical arcing in the power cord.

4. ECRI searched FDA's MAUDE database for reports from 2008 through June 2018 and found the following:

a) Five reports of electrical fires that occurred due to fluid ingress in a vessel sealing handpiece, a syringe pump power supply, an infusion pump battery pack, and the power cord sockets of a hemodynamic monitoring unit and a syringe pump.

b) Four reports of charring that occurred due to fluid ingress in circuit boards of three infusion pump battery modules (see report numbers 1314492-2017-021701314492-2017-02171, and 1314492-2017-02172), and in the power cord socket of an infusion pump power supply.

c) One report of fluid ingress in an autotransfusion system without known electrical damage.

Glossary

Bibliography

References

Resource List

Related Resources

2019 Top 10 Health Technology Hazards

 

Member Resources

The following resources are accessible to members of ECRI's Health Devices, Health Devices Gold, and SELECTplus programs.

1. Cleaner and disinfectant fluid ingress in electrical medical devices and electrical equipment may cause equipment damage and fires [ECRI Exclusive Hazard Report]. Health Devices Alerts 2018 Jun 28 (Accession No. H0447).

2. Breaking badly: equipment failures from improper cleaning. Health Devices web conference 2018 Jun 27.

3. How improper cleaning can damage medical equipment. Health Devices 2017 Aug 16.

4. Improper cleaning may cause device malfunctions, equipment failures, and potential for patient injury. Hazard #5—top 10 health technology hazards for 2018. Health Devices 2017 Nov 1.

5. Skytron—various OR tables: power cord covers can minimize fire risk from liquid ingress into power receptacle [ECRI Exclusive Hazard Report]. Health Devices Alerts 2016 Dec 8 (Accession No. H0352).

 

References and Additional Resources

1. Campbell JA, Howell SM. Know as arcs—in-line & wet-wire electrical fires. Triodyne Inc. Safety Bulletin 1998 Aug;7(3).

2. National Fire Protection Association (NFPA). NFPA 921: guide for fire and explosion investigations. 2017.

Topics and Metadata

Topics

Bariatric Medicine; Biomedical Engineering; Culture of Safety; Equipment and Facility Planning; Infection Control; Infusion Therapy; Long-term Care; Men's Health; Occupational Health; Patient Transport; Quality Assurance/Risk Management; Robotics; Service and Maintenance; Sterilization and Reprocessing; Technology Selection; Women's Healthcare; Wound Care

Caresetting

Ambulatory Care Center; Ambulatory Surgery Center; Assisted-living Facility; Behavioral Health Facility; Dialysis Facility; Emergency Department; Endoscopy Facility; Home Care; Hospice; Hospital Inpatient; Hospital Outpatient; Imaging Center; Independent Living Facility; Physician Practice; Rehabilitation Facility; Short-stay Facility; Skilled-nursing Facility; Substance Abuse Treatment Facility; Trauma Center

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Anesthesiology; Bariatrics; Cardiothoracic Surgery; Cardiovascular Medicine; Critical Care; Emergency Medicine; Hospital Medicine; Infectious Disease; Internal Medicine; Maternal and Fetal Medicine; Nursing; Obstetrics; Oncology; Orthopedics; Pain Management; Primary Care; Pulmonary Medicine; Radiation Oncology; Surgery; Transplantation; Urology

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Allied Health Personnel; Biomedical/Clinical Engineer; Clinical Practitioner; Environmental Services Manager; Infection Preventionist; Materials Manager/Procurement Manager; Nurse; Quality Assurance Manager; Regulator/Policy Maker; Risk Manager

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