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.