PERFUSION REPORTS

REPORT

009

DATE

1/2/2012

TITLE

Similarity In Heparin And St Thomas Cardioplegia Ampules

DETAILS OF INCIDENT

It has recently come to the attention of the Safety Committee of a potential issue regarding two different drug ampoules that look very similar. The drugs in question are Heparin and St. Thomas’s Cardioplegia. The Safety Committee would strongly recommend the use of double-checking for all drugs that are used by the Perfusionist. If you have experience of this or different drug ampoules causing potential confusion please use the Web Reporting form on this site to let us know.

DETAILS OF INJURY TO PATIENT

TYPE OF DEVICE/MANUFACTURER

ACTION TAKEN

N/A

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

092



1/10/21

Vapourizer Issue

REPORT NO

091



1/10/21

Oyxgenator Leak

REPORT NO

090



1/10/21

Breach of chemical cleaner

REPORT NO

089



1/9/21

Sechrist Gas Blender Sweep on ECMO

REPORT NO

088



1/9/21

Oxygenator High Pressure Events

REPORT NO

087



1/10/21

Leaking one way valve

REPORT NO

086



1/7/21

Electronic Gas Blender Fault

REPORT NO

085



1/2/21

Protamine Administration Issue

REPORT NO

084



1/6/21

Damaged roller pump lid

REPORT NO

083



1/6/21

IABP malfunction

REPORT NO

082



1/1/21

Accidental cardioplegia administration

REPORT NO

081



1/4/21

S5 Double Roller Pump incident

REPORT NO

080



1/5/21

Human factors issue

REPORT NO

079



1/6/21

Centrimag battery module failure

REPORT NO

078



1/6/21

Sampling manifold valve fault

REPORT NO

077



1/5/21

IABP transport issue

REPORT NO

076



1/4/21

Modified Ultrafiltration (MUF) Issue

REPORT NO

075



1/3/21

Electromagnetic interference with HLM

REPORT NO

074



1/2/21

HCU40 Failure

REPORT NO

073



1/2/21

HCU40 valve failures

REPORT NO

072



1/1/21

HCU40 failure

REPORT NO

071



1/1/21

LIVA NOVA STATEMENT ON CENTRIFUGAL HEAD

REPORT NO

070



1/1/21

Loose component on circuit

REPORT NO

069



1/12/20

Centrifugal Head noise

REPORT NO

068



1/11/20

Venous Reservoir disposable issue

REPORT NO

067



1/11/20

Failure of Heater Cooler due to leaking valves

REPORT NO

066



1/11/20

Failure of Valves on heater cooler unit

REPORT NO

065



1/9/20

Intra Aortic Balloon Pump (IABP) Failure

REPORT NO

064



1/9/20

Centrifugal head failure

REPORT NO

063



1/8/20

Centrifugal head issue 4

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