PERFUSION REPORTS

REPORT
032
DATE
TITLE
Sucker Placed In Raceway In Wrong Direction
DETAILS OF INCIDENT

A very unusual emergency for a Thoracic procedure occurred where, the perfusion and cardiopulmonary bypass support was requested. The dry build pump which was set up earlier has been wheeled in to the emergency theatre (Non cardiac). It was necessary to institute femoral-femoral CPB to support the patient in an uncontrolled and extremely quick situation. The emergency was such and the instability of patient made the sucker test not performed before it was put in the pleura (patient was heparinised and ACT was greater than 250 secs).

It was made obvious from the scrub team that the sucker from the was set up in wrong direction and was blowing rather than sucking. Due to the experience of the perfusionist the tubing was quickly changed and no consequence to the patient was seen.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

N/A

ACTION TAKEN

The manager has been informed and local DATIX has been filled in.

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION

N/A

SUPPORTING VISUALS/VIDEO

N/A

SUPPORTING DOCUMENT

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