PERFUSION REPORTS

REPORT

022

DATE

TITLE

Vent Pump Boot Tubing Inserted In Wrong Way Round

DETAILS OF INCIDENT

Vent Pump Boot tubing inserted in pump the wrong way round. Wet test failed to show up.
New bypass machines were in use.
The tubing pack was still under modification to fit new machines. Vent sucker required extending to reach new reservoir position.
Wet test performed by scrub person and confirmed as being okay. PA vent inserted, surgeon immediately reports that there was no suction. Suction was stopped and the occlusion was checked, but still no suction. Wet test repeated and the vent observed blowing bubbles. The perfusionist spots a pump boot error and reverses the boot into the correct orientation. Wet test repeated, vent observed sucking. Case proceeds as normal. Anaesthetist was viewing TOE throughout and reported no air. Patient recovered as normal.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

N/A

ACTION TAKEN

Discussed and raised awareness of potential errors with the introduction of new equipment. Modification of tubing sets to eliminate the need to extend the vent sucker and also increase the visibility of the connector for the vent at the inlet side of the pump. Review of all sucker tubing indicators in the operative field.
Increased robustness of wet test.
It was felt that the failure of the wet test may have been due to the use of a connecting silicone 'U' bend that connects 3/8th inch arterial to 1/2 inch venous in the tubing sash. This is cut out of the system by the scrub person and retains some priming fluid which was being dipped into for the wet test. It may have indicated a positive result as a sucker tip pushed into the 3/8th inch side of the 'U' could displace fluid up the 1/2 inch side which would then naturally swing back up the sucker tip. Based on this the wet test is now performed from an open jug and visualised and confirmed by the perfusionist and the scrub person.
One way valves in all suction lines was highlighted as well as a final dip test by the operator prior to insertion of intra cardiac suction. Neither of these measures are currently in place.
Better indicators on the pump for direction off flow are being explored.

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION

N/A

SUPPORTING VISUALS/VIDEO

N/A

SUPPORTING DOCUMENT

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