Inspection Detail

Inspection: 1490500.015 - Omnicell, Inc.

Inspection Information - Office: Madison Area Office

Investigation Summary

At 4:30 p.m. on August 24, 2020, an employee and a coworker working as service technicians had reported to had reported to the central pharmacy of a university hospital to perform repairs. They were troubleshooting an a Bellheimer Metallwerk System 180 model: SYS-180-0916.25-NT pharmacy carousel (serial number 05000824/001). The employee and the coworker had arrived separately to work on the carousel. The carousel is used to dispense medications to pharmacy technicians. The employee was positioned partially inside the operating envelope of the carousel in order to observe the internal parts when a pharmacy technician entered a medication order into the control system for the carousel. The carousel began cycling, and parts of the suspension system of the carousel came down on the employee. The employee had reenergized the carousel following lockout and repairs in order to jog the carousel to ensure repairs were completed adequately. However, the employee had not disconnected the control cable between the carousel and the control as required. The employer had a documented lockout/tagout program and procedure that was specific to the System 180 carousel. This specific procedure also addresses the isolation and lockout of the communication cable. The employee and the coworker had forgotten to unplug this cable. The employee and coworker had received training on the company's lockout/tagout program and specific energy control procedures including the System 180 lockout procedure. According to company management, these field employees were not routinely supervised or audited by the company to ensure adherence to safety and health requirements such as lockout/tagout. The employee fractured his ribs and sustained a pneumothorax and contusions and was hospitalized.

Keywords: Cable, Catch Point, Caught In, Chest, Contusion, Crushed, Fracture, Hospital, Insufficient Supervision, Lockout, Lockout/Tagout, Lung, Machine Cycled, Machine operator, Repair, Rib, Service Technician, Technician