PERFUSION REPORTS

REPORT
001
DATE
1/1/2009
TITLE
Oxygenator Water To Blood Leak
DETAILS OF INCIDENT

Following a recent safety incident where, due to a heat exchanger fault, a water to blood leak occurred in an oxygenator.

DETAILS OF INJURY TO PATIENT
TYPE OF DEVICE/MANUFACTURER
ACTION TAKEN

The Safety Committee would like to re-affirm that water-side leak are checked for before the oxygenator is primed for cardiopulmonary bypass and that the manufacturers¹ instructions for use (IFU) are followed when
setting up and priming an oxygenator.

The Safety Committee also recommends that departmental protocols clearly state the above.

RESPONSE FROM MANUFACTURER
ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION
 REPORTS

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REPORT NO
002
1/1/10
Luer Cap Found In Venous Inlet Port
REPORT NO
001
1/1/09
Oxygenator Water To Blood Leak
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