PERFUSION REPORTS

REPORT

020

DATE

TITLE

S3 E62 Pump Error

DETAILS OF INCIDENT

S3 pump control knob unresponsive and unable to increase or decrease blood flow on bypass. E62 error noted on control panel. RPM remained fixed but flashed visibly to 0 RPM whilst blood flow readings remained constant.

If control knob turned to reduce or increase RPM, there was no response however, LED dot marked the current RPM value.

‍

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

N/A

ACTION TAKEN

The fault occurred 10 mins before the end of bypass during de-airing of the heart after mitral surgery.
The surgeon informed of fault and second perfusionist brought into theatre for support.
Unable to reach calculated flow, blood gases were monitored closely to ensure adequate perfusion.
Patient tolerated enforced low flow levels.
De-airing of the heart performed using clamps to control blood outflow from the pump unit.
Patient weaned from bypass safely again using clamps.
Pump rebooted once safely off bypass which cleared the fault.
Critical incident reported at local level.
Heart lung machine removed from service and colleagues informed of incident.

RESPONSE FROM MANUFACTURER

Sorin engineer called to investigate and replace the faulty unit. Thought to be a fault with the drive unit not the control panel.

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

123



5/7/24

Hardware Fault

REPORT NO

122



5/4/24

Oxygenator Failure

REPORT NO

121



8/3/24

Disposables: Eurosets Adult ECMO Oxygenator

REPORT NO

120



1/5/24

Disposable Incident

REPORT NO

119



Hardware: HCU Contamination

REPORT NO

118



12/9/23

Human Factors: ECMO Mobilisation

REPORT NO

117



27/9/23

Disposables: Oxygenator

REPORT NO

116



14/9/23

Disposable Issue: Reservoir in CPB circuit

REPORT NO

115



13/9/23

Disposable Error

REPORT NO

114



13/7/23

Dispoables

REPORT NO

112



20/2/23

HLM Hardware Error: S5 HLM - Dual roller cardioplegia

REPORT NO

111



10/2/23

Human Factors

REPORT NO

110



31/1/23

DISPOSABLE FAULT

REPORT NO

109



19/1/23

Disposable issue

REPORT NO

108



3/1/23

Disposable issue: Oxygenator leak

REPORT NO

107



6/12/22

Hardware fault. Electronic gas Blender failure

REPORT NO

106



1/11/22

ECG Interference

REPORT NO

105



9/9/22

Issue with use of disposable

REPORT NO

104



13/6/22

Human Factors

REPORT NO

103



25/7/22

Human Factors

REPORT NO

102



7/7/22

Disposable issue

REPORT NO

101



6/4/21

Irregular blood flow/foreign looking substance in Oxygenator

REPORT NO

100



20/4/22

Gas Line Filter Fault

REPORT NO

099



20/4/22

Human Factors: BiVAD Error

REPORT NO

098



4/4/22

REPORT NO

097



19/3/22

Disposables Issue

REPORT NO

096



18/3/22

Bubbles Sensor Activation

REPORT NO

095



1/1/22

Protamine Administration

REPORT NO

094



1/11/21

Oxygenation failure upon commencement of CPB

REPORT NO

093



1/11/21

Detached bullet tip of sump-updated response Sep 2022

Perfusion Report cards are shown in batches of 30 at any one time where available.

123

122

121

120

119

118

117

116

115

114

112

111

110

109

108

107

106

105

104

103

102

101

100

099

098

097

096

095

094

093

092

091

090

089

088

087

086

085

084

083

082

081

080

079

078

077

076

075

074

073

072

071

070

069

068

067

066

065

064

063

062

061

060

059

058

057

056

055

054

053

052

051

050

049

048

047

046

045

044

043

042

041

040

039

038

037

036

035

034

033

032

031

030

029

028

027

026

025

024

023

Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.

USEFUL LINKS

BACK TO SAFETY ARCHIVE SAFETY - SUBMIT A REPORT SAFETY COMMITTEE SAFETY CONTACTS

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Copyright © 2024. The Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland.

DMCA.com Protection Status

Made With  By MojoPixels‍