PERFUSION REPORTS

REPORT

002

DATE

1/1/2010

TITLE

Luer Cap Found In Venous Inlet Port

DETAILS OF INCIDENT

After instigating cardiopulmonary bypass for an urgent procedure, it was noticed the venous return was not satisfactory to sustain full flow despite surgical manipulation. CPB was discontinued, the venous line disconnected at the inlet of the venous reservoir where a non-hospital standard luer cap was found lodged inside the venous inlet port. This was removed, CPB re-instituted and no further problems were encountered. No harm came to the patient.

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DETAILS OF INJURY TO PATIENT

TYPE OF DEVICE/MANUFACTURER

ACTION TAKEN

The Safety Committee recommends that a thorough inspection of all blood path ports be made during circuit assembly and suitable flow and pressure checks be performed prior to establishing CPB. Consider incorporating into departmental checklists if not already included.

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RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

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Perfusion Report cards are shown in batches of 30 at any one time where available.

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