PERFUSION REPORTS

REPORT

003

DATE

1/2/2010

TITLE

Difficulties In Visualising Blender Reading

DETAILS OF INCIDENT

Whilst using a mechanical gas blender the first gas on cardiopulmonary bypass showed a very low pCO2. Reducing gas flow rates made no difference. Swapping out the blender resolved the problem. On inspection the fine trim rotameter knob was found to be fully open delivering a gas flow in excess of 30L/min. When fully open the small ball float is difficult to visualise.

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DETAILS OF INJURY TO PATIENT

TYPE OF DEVICE/MANUFACTURER

ACTION TAKEN

The Safety Committee recommends that a check is made on the gas blender to ensure that the rotameter knobs are correctly set 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

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

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032

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029

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Sorin Inspire 8F Blood Leak From Temperature Port

REPORT NO

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Sorin Inspire 8F Oxygenator Detached From Holding Arm

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Paragon Oxygenator Gas Inlet Leak

REPORT NO

026

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Maquet IABP Console Failure

REPORT NO

025

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Sorin EOS Gas To Blood Leak Whilst Priming

REPORT NO

024

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Chalice Paragon Midi Heat Exchanger Leak Whilst Priming

REPORT NO

023

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Chalice Paragon Heat Exchanger Water To Blood Leak

REPORT NO

022

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Vent Pump Boot Tubing Inserted In Wrong Way Round

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021

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S3 E62 Pump Error

REPORT NO

019

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Medtronic Potential Oxygenator Leak

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018

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Medos Heat Exchanger Leak

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017

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REPORT NO

016

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Additional Sucker Incorrectly Placed In Raceway

REPORT NO

015



Large Perished Tear Observed On Tubing At Back Of Vaporiser

REPORT NO

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REPORT NO

013

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Isoflurane Vaporiser Seal Leak Due To Malposition

REPORT NO

012

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1/2/13

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REPORT NO

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1/1/13

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1/3/12

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REPORT NO

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1/5/11

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1/4/11

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REPORT NO

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1/2/11

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1/1/11

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1/2/10

Difficulties In Visualising Blender Reading

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