OTHER PERFUSION
REPORTS
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REPORT NO
002
1/1/10
Luer Cap Found In Venous Inlet Port
REPORT NO
001
1/1/09
Oxygenator Water To Blood Leak
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