PERFUSION REPORTS

REPORT

016

DATE

TITLE

Additional Sucker Incorrectly Placed In Raceway

DETAILS OF INCIDENT

Trainee Perfusionist added an extra sucker to a pre built circuit & failed to complete the 3 perfusion sucker checks. The 4th and final sucker check, a visual wet test of the suckers with the scrub nurse was only completed for 2 of the 3 suckers i.e. not the additional sucker.

The additional sucker was used as a vent and after x clamping the surgeon asked for the vent to be turned on and noted it was blowing not sucking, this was switched off and corrected. The surgeon was adamant that the Aorta was X clamped before the vent was switched on and that no air entered the patient.

DETAILS OF INJURY TO PATIENT

Post operatively the patient showed Lt sided stroke and the family was informed of the incident involving the reversed suction tubing.

The patient and family have been kept fully informed as to the possible reasons for the stroke - and that stroke is a known risk from cardiac surgery and cardiopulmonary bypass.

The family has also been kept fully informed of the mistakes made during setup and checking of the suckers.

TYPE OF DEVICE/MANUFACTURER

N/A

ACTION TAKEN

A Hospital Incident Report was filed on the day of the incident. A panel met and discussed the incident and decided to conduct a full SUI investigation with outcome of investigation sent to family and the SHA.

A full review of practices has been undertaken, this has resulted in a number of changes to procedure and/or protocols.

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION

N/A

SUPPORTING VISUALS/VIDEO

N/A

SUPPORTING DOCUMENT

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