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

OTHER PERFUSION
REPORTS

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REPORT NO

032



Sucker Placed In Raceway In Wrong Direction

REPORT NO

031



High Transmembrane Pressure Gradients

REPORT NO

030



Faulty Connector On ECMO Soft Shell Reservoir Bag

REPORT NO

029



Sorin Inspire 8F Blood Leak From Temperature Port

REPORT NO

028



Sorin Inspire 8F Oxygenator Detached From Holding Arm

REPORT NO

027



Paragon Oxygenator Gas Inlet Leak

REPORT NO

026



Maquet IABP Console Failure

REPORT NO

025



Sorin EOS Gas To Blood Leak Whilst Priming

REPORT NO

024



Chalice Paragon Midi Heat Exchanger Leak Whilst Priming

REPORT NO

023



Chalice Paragon Heat Exchanger Water To Blood Leak

REPORT NO

022



Vent Pump Boot Tubing Inserted In Wrong Way Round

REPORT NO

021



Paragon Oxygenator Heat Exchanger Leak

REPORT NO

020



S3 E62 Pump Error

REPORT NO

019



Medtronic Potential Oxygenator Leak

REPORT NO

018



Medos Heat Exchanger Leak

REPORT NO

017



Avant D903 Has A Dual Chamber Reservoir Leak

REPORT NO

016



Additional Sucker Incorrectly Placed In Raceway

REPORT NO

015



Large Perished Tear Observed On Tubing At Back Of Vaporiser

REPORT NO

014



Gas Blender Flow Control Immobilised

REPORT NO

013



Isoflurane Vaporiser Seal Leak Due To Malposition

REPORT NO

012



1/2/13

Hypercoagulable Disorder May Have Led To Oxygenator Failure

REPORT NO

011



1/1/13

LV Vent Placed In Raceway In Wrong Direction

REPORT NO

010



1/3/12

Sucker Placed In Raceway In Wrong Direction

REPORT NO

009



1/2/12

Similarity In Heparin And St Thomas Cardioplegia Ampules

REPORT NO

008



1/7/11

Aorta Remained Clamped Post CPB

REPORT NO

007



1/5/11

Deficiencies In The QC At Terumo Ann Arbor, USA.

REPORT NO

006



1/4/11

Awareness Of Suckers When Using Bio-Glues

REPORT NO

005



1/2/11

Patient Exsanguinated From Additional Venous Line Post CPB

REPORT NO

004



1/1/11

Possible Inaccuracies In Colloid Research

REPORT NO

003



1/2/10

Difficulties In Visualising Blender Reading

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