OTHER PERFUSION
REPORTS
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REPORT NO
032
Sucker Placed In Raceway In Wrong Direction
REPORT NO
031
High Transmembrane Pressure Gradients
REPORT NO
030
Faulty Connector On ECMO Soft Shell Reservoir Bag
REPORT NO
029
Sorin Inspire 8F Blood Leak From Temperature Port
REPORT NO
028
Sorin Inspire 8F Oxygenator Detached From Holding Arm
REPORT NO
027
Paragon Oxygenator Gas Inlet Leak
REPORT NO
026
Maquet IABP Console Failure
REPORT NO
025
Sorin EOS Gas To Blood Leak Whilst Priming
REPORT NO
024
Chalice Paragon Midi Heat Exchanger Leak Whilst Priming
REPORT NO
023
Chalice Paragon Heat Exchanger Water To Blood Leak
REPORT NO
022
Vent Pump Boot Tubing Inserted In Wrong Way Round
REPORT NO
021
Paragon Oxygenator Heat Exchanger Leak
REPORT NO
020
S3 E62 Pump Error
REPORT NO
019
Medtronic Potential Oxygenator Leak
REPORT NO
018
Medos Heat Exchanger Leak
REPORT NO
017
Avant D903 Has A Dual Chamber Reservoir Leak
REPORT NO
016
Additional Sucker Incorrectly Placed In Raceway
REPORT NO
015
Large Perished Tear Observed On Tubing At Back Of Vaporiser
REPORT NO
014
Gas Blender Flow Control Immobilised
REPORT NO
013
Isoflurane Vaporiser Seal Leak Due To Malposition
REPORT NO
012
1/2/13
Hypercoagulable Disorder May Have Led To Oxygenator Failure
REPORT NO
011
1/1/13
LV Vent Placed In Raceway In Wrong Direction
REPORT NO
010
1/3/12
Sucker Placed In Raceway In Wrong Direction
REPORT NO
009
1/2/12
Similarity In Heparin And St Thomas Cardioplegia Ampules
REPORT NO
008
1/7/11
Aorta Remained Clamped Post CPB
REPORT NO
007
1/5/11
Deficiencies In The QC At Terumo Ann Arbor, USA.
REPORT NO
006
1/4/11
Awareness Of Suckers When Using Bio-Glues
REPORT NO
005
1/2/11
Patient Exsanguinated From Additional Venous Line Post CPB
REPORT NO
004
1/1/11
Possible Inaccuracies In Colloid Research
REPORT NO
003
1/2/10
Difficulties In Visualising Blender Reading
Perfusion Report cards are shown in batches of 30 at any one time where available.
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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