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

Select and scroll to view chosen report

REPORT NO

062



1/8/20

Human Factors Issue

REPORT NO

061



1/8/20

LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE

REPORT NO

060



1/8/20

Oxygenator Fibre Leak

REPORT NO

059



1/5/20

Failure to remove CO2 effectively

REPORT NO

058



1/7/20

Centrifugal Head Issue 3

REPORT NO

057



1/6/20

Centrifugal Head Issue 2

REPORT NO

056



1/1/20

Centrifugal Head Issue

REPORT NO

055



1/2/20

Faulty Pressure Relief Valves

REPORT NO

054



1/4/20

Leaking ALF

REPORT NO

053



1/2/20

Arterial Line Filter Leak

REPORT NO

052



1/3/19

Gas Line Filter Issue

REPORT NO

051



1/12/19

Dual Lumen Cannula Movement

REPORT NO

050



1/10/19

Venous Cannula Damaged

REPORT NO

049



1/12/19

Oxygenation Issue

REPORT NO

048



1/8/19

Roller Pump Failure

REPORT NO

047



1/12/19

Broken Cannula Dilator

REPORT NO

046



6/12/19

Gas Blender Error

REPORT NO

045



20/11/19

Tubing Detachments

REPORT NO

044



27/11/19

Interruption to IABP counterpulsation

REPORT NO

043



1/7/19

Getinge Mal-Position Of IABP Catheter

REPORT NO

042



1/2/19

Avalon Dual Lumen Cannula Crack

REPORT NO

041



1/2/19

Custodial Rubber Fragmentation In Spiked Bag

REPORT NO

040



1/10/18

Reservoir Clot

REPORT NO

039



1/10/18

Pall Clot In Cardioplegia Circuit

REPORT NO

038



1/10/18

Maquet HL20 Cardioplegia Pump Error

REPORT NO

037



1/10/17

Temed D200 Haemoconcentrator Clot

REPORT NO

036



1/10/17

Oxygenator issue

REPORT NO

035



1/10/17

Medtronic Fusion Oxygenator Blood To Gas Leak

REPORT NO

034



Possible Medtronic Fusion Oxygenator Failure

REPORT NO

033



Fannin Heparin Ampules Shattering

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