PERFUSION REPORTS

REPORT

046

DATE

6/12/2019

TITLE

Gas Blender Error

DETAILS OF INCIDENT

There was an electronic Gas Blender Error – Code E19, in the preoperative period.

The error code appeared continually on the electronic blender without an audible alarm from the blender itself. There was however a continual audible and visual alarm from the system display module.

When the error message was displayed, there was still flow through the oxygen tubing and oxygen concentration had not been affected, however the error message remained and could not be reset.

This alarm is not referred to in the manufacturers manual.

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DETAILS OF INJURY TO PATIENT

None as the incident occurred preoperatively

TYPE OF DEVICE/MANUFACTURER

Stockert Electronic Blender with S5

ACTION TAKEN

The electronic gas blender was switched out for another blender.

The control panel that controlled the gas blender also controlled the heater cooler unit. The heater cooler controls were still functioning, however the module was changed out to rule out a module issue but the same fault was still displayed. The faulty blender was removed from the department and sent to Liva Nova for inspection.

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RESPONSE FROM MANUFACTURER

None yet received.

ADDTIONAL INFORMATION

Upon reflection what do you think went well?

The affected gas blender was changed out without any issue.

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

None

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

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REPORT NO

123



5/7/24

Hardware Fault

REPORT NO

122



5/4/24

Oxygenator Failure

REPORT NO

121



8/3/24

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REPORT NO

120



1/5/24

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119



Hardware: HCU Contamination

REPORT NO

118



12/9/23

Human Factors: ECMO Mobilisation

REPORT NO

117



27/9/23

Disposables: Oxygenator

REPORT NO

116



14/9/23

Disposable Issue: Reservoir in CPB circuit

REPORT NO

115



13/9/23

Disposable Error

REPORT NO

114



13/7/23

Dispoables

REPORT NO

112



20/2/23

HLM Hardware Error: S5 HLM - Dual roller cardioplegia

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111



10/2/23

Human Factors

REPORT NO

110



31/1/23

DISPOSABLE FAULT

REPORT NO

109



19/1/23

Disposable issue

REPORT NO

108



3/1/23

Disposable issue: Oxygenator leak

REPORT NO

107



6/12/22

Hardware fault. Electronic gas Blender failure

REPORT NO

106



1/11/22

ECG Interference

REPORT NO

105



9/9/22

Issue with use of disposable

REPORT NO

104



13/6/22

Human Factors

REPORT NO

103



25/7/22

Human Factors

REPORT NO

102



7/7/22

Disposable issue

REPORT NO

101



6/4/21

Irregular blood flow/foreign looking substance in Oxygenator

REPORT NO

100



20/4/22

Gas Line Filter Fault

REPORT NO

099



20/4/22

Human Factors: BiVAD Error

REPORT NO

098



4/4/22

REPORT NO

097



19/3/22

Disposables Issue

REPORT NO

096



18/3/22

Bubbles Sensor Activation

REPORT NO

095



1/1/22

Protamine Administration

REPORT NO

094



1/11/21

Oxygenation failure upon commencement of CPB

REPORT NO

093



1/11/21

Detached bullet tip of sump-updated response Sep 2022

Perfusion Report cards are shown in batches of 30 at any one time where available.

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