Archived Perfusion Report - 048

PERFUSION REPORTS

REPORT

048

DATE

1/8/2019

TITLE

Roller Pump Failure

DETAILS OF INCIDENT

50 minutes into cardiopulmonary bypass for a routine CABG the main arterial roller pump stopped abruptly and the malfunction alarm appeared on the control mast. The pump was rebooted with no response.

Hand cranking was commenced at this point. The pump was powered down again and rebooted, this corrected the malfunction alarm.

Cardiopulmonary bypass was restarted with no further issues.

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DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Stockert S5

ACTION TAKEN

The pump was examined and serviced by Liva Nova and a report was raised. No issues or faults were detected-it was likely a software issue.

An incident report was submitted to risk management.

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

Upon reflection what do you think went well?

Staff went through the correct steps and emergency procedures to rectify the problem in a timely fashion.

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

Pumps are due for replacement later this year.

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SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

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Centrifugal head issue 4

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