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While Sunrise Medical staff were transferring a morbidly
obsess patient in a portable lift, the hook holding the patient disengaged from
the lift, the patient fell to the ground, and was severely injured.
We investigated this loss, reconstructed the accident,
performed a metallurgical analysis of failed nuts, and determined that the lift
had been altered and had not been maintained.
The castle head nut and retaining pin that held the hook in place had
been removed and replaced with a normal nut without a pin. This replacement nut had worn severely and
simply rotated off the end of the threaded hook. There was no evidence of failure of the
original equipment.
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