BIOMEDICAL ENGINEERING DEPARTMENT

PLANNED PREVENTIVE MAINTENANCE (PPM)

INFUSION PUMP INSPECTION FORM

WO#: 201910 .
DATE: LOCATION: SYSTEM COMPONENTS STATUS
REF/INVENTORY NO.: SERIAL NO: CONTROL NO. DESCRIPTION PASS ( )
PPM FREQUENCY: SEMI ANNUALY MODEL NO.: SERVICE REQUIRED ( )
INSPECTOR: ARJAY ST EQUIPMENT NAME: REMOVE FROM USE ( )
INFUSION PUMP

1 PASS FAIL QUANTITATIVE TASK COMMENTS 2 PASS FAIL QUANTITATIVE TASK RESULT
A. APPEARANCE CHECK 2.1 GROUNDING RESISTANCE (<0.5 Ohms)
1.1 CHASIS/HOUSING 2.2 EARTH LEAKAGE CURRENT (<100 NC)
1.2 OPERATION PANEL (<500 SFC)
B. INFUSION RATE TIME VOLUME ACCEPTABLE RANGE 2.3
1.3 TOP H 600ML/H 47.5-52.5 ML 2.4
GENERAL PURPSE 150 ML/H 13.5-16.5 ML 3 CHECK IF DESCRIPTION AND
PM
C. ALARM FUNCTION AND CONFIRMATION DONE COMMENTS
1.5 DOOR OPEN 3.1 CLEAN
1.6 OCCLUSION 3.2 LUBRICATE
1.7 AIR INLINE 3.3 CALIBRATTE
D. OTHER TASK 3.4 ADJUST
1.9 STRAIN RELIEF 3.5 REPLACE
1.10 FITTINGS/CONNECTORS
1.11 LINE CORD
1.13 CONTROLS/SWITCHES
1.14 AC PLUG/RECEPTACLE TIME STARTED: TIME COMPLETED: . TIME RECURED: HOURS
1.15 MOTOR/PUMP/FAN/COMP.
1.16 Circuit Breaker/FUSE COMMENTS:
1.17 BATTERY/CHARGER
1.18 INDICATORS/DISPLAY
1.19 USER CAL./SELF TEST
1.21 AUDIBLE SIGNALS NEXT IPM DUE: . (DD/MM/YYYY)

1.22 LABELING
1.23 ACCESSORIES CHECKED BY: END USER ON DUTY NAME: . SIGNATURE: .

Date: .

PREPARED BY: ARJAY TAGUIAM