PERFUSION REPORTS

REPORT

025

DATE

TITLE

Sorin EOS Gas To Blood Leak Whilst Priming

DETAILS OF INCIDENT

Once the pump was primed and left circulating in theatre, it was noticed that there were bubbles in the prime. Gas was leaking from the gas phase into the blood phase from the bottom of the oxygenator module (Sorin EOS). The pump and oxygenator were removed from theatre and swapped out for a new one.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

N/A

ACTION TAKEN

Pump/oxy swapped out, device returned to manufacturer for investigation.

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION

N/A

SUPPORTING VISUALS/VIDEO

N/A

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

062



1/8/20

Human Factors Issue

REPORT NO

061



1/8/20

LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE

REPORT NO

060



1/8/20

Oxygenator Fibre Leak

REPORT NO

059



1/5/20

Failure to remove CO2 effectively

REPORT NO

058



1/7/20

Centrifugal Head Issue 3

REPORT NO

057



1/6/20

Centrifugal Head Issue 2

REPORT NO

056



1/1/20

Centrifugal Head Issue

REPORT NO

055



1/2/20

Faulty Pressure Relief Valves

REPORT NO

054



1/4/20

Leaking ALF

REPORT NO

053



1/2/20

Arterial Line Filter Leak

REPORT NO

052



1/3/19

Gas Line Filter Issue

REPORT NO

051



1/12/19

Dual Lumen Cannula Movement

REPORT NO

050



1/10/19

Venous Cannula Damaged

REPORT NO

049



1/12/19

Oxygenation Issue

REPORT NO

048



1/8/19

Roller Pump Failure

REPORT NO

047



1/12/19

Broken Cannula Dilator

REPORT NO

046



6/12/19

Gas Blender Error

REPORT NO

045



20/11/19

Tubing Detachments

REPORT NO

044



27/11/19

Interruption to IABP counterpulsation

REPORT NO

043



1/7/19

Getinge Mal-Position Of IABP Catheter

REPORT NO

042



1/2/19

Avalon Dual Lumen Cannula Crack

REPORT NO

041



1/2/19

Custodial Rubber Fragmentation In Spiked Bag

REPORT NO

040



1/10/18

Reservoir Clot

REPORT NO

039



1/10/18

Pall Clot In Cardioplegia Circuit

REPORT NO

038



1/10/18

Maquet HL20 Cardioplegia Pump Error

REPORT NO

037



1/10/17

Temed D200 Haemoconcentrator Clot

REPORT NO

036



1/10/17

Oxygenator issue

REPORT NO

035



1/10/17

Medtronic Fusion Oxygenator Blood To Gas Leak

REPORT NO

034



Possible Medtronic Fusion Oxygenator Failure

REPORT NO

033



Fannin Heparin Ampules Shattering

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