PERFUSION REPORTS

REPORT

045

DATE

20/11/2019

TITLE

Tubing Detachments

DETAILS OF INCIDENT

Three separate events with tubing.

1) Pump boot detachment of PVC tubing and connector made under moderate pressure.

2) Tubing detachment at 3/8 x 3/8 x 1/4 inch connector under pressure alarm test conditions.

3) Detachment of U bend PVC attachment within sash whilst handled by surgical staff.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Terumo tubing disposables

ACTION TAKEN

In the first two incidences the circuit connections were all cable tied.

In the third incident the detachment was noticed and no changes were made.

The perfusion team have been made aware that there may be an issue with the glue of the circuit. The company has been informed and has collected one of the circuits for testing.

‍

RESPONSE FROM MANUFACTURER

The manufacturer was unable to test the circuit collected as they stated it had not been flushed of blood sufficiently.

ADDTIONAL INFORMATION

Upon reflection what do you think went well?

All circuit failures were detected during set up or during handling of the sash by surgical staff. In all cases the perfusion team were able to re-enforce the connections,pressure test them and continue. Issues were dealt with appropriately by the perfusion team and did not require delays to surgery.

New action plans/changes as a result of the event?

All team members are aware of potential issues with tubing.

Any future incidences will be documented and shared with the team.

The decontamination process required by the supplier is being reviewed to ensure it is not too onerous and does not add risk to staff.

‍

MHRA informed

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