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.

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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