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
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