OTHER PERFUSION
REPORTS
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REPORT NO
092
1/10/21
Vapourizer Issue
REPORT NO
091
1/10/21
Oyxgenator Leak
REPORT NO
090
1/10/21
Breach of chemical cleaner
REPORT NO
089
1/9/21
Sechrist Gas Blender Sweep on ECMO
REPORT NO
088
1/9/21
Oxygenator High Pressure Events
REPORT NO
087
1/10/21
Leaking one way valve
REPORT NO
086
1/7/21
Electronic Gas Blender Fault
REPORT NO
085
1/2/21
Protamine Administration Issue
REPORT NO
084
1/6/21
Damaged roller pump lid
REPORT NO
083
1/6/21
IABP malfunction
REPORT NO
082
1/1/21
Accidental cardioplegia administration
REPORT NO
081
1/4/21
S5 Double Roller Pump incident
REPORT NO
080
1/5/21
Human factors issue
REPORT NO
079
1/6/21
Centrimag battery module failure
REPORT NO
078
1/6/21
Sampling manifold valve fault
REPORT NO
077
1/5/21
IABP transport issue
REPORT NO
076
1/4/21
Modified Ultrafiltration (MUF) Issue
REPORT NO
075
1/3/21
Electromagnetic interference with HLM
REPORT NO
074
1/2/21
HCU40 Failure
REPORT NO
073
1/2/21
HCU40 valve failures
REPORT NO
072
1/1/21
HCU40 failure
REPORT NO
071
1/1/21
LIVA NOVA STATEMENT ON CENTRIFUGAL HEAD
REPORT NO
070
1/1/21
Loose component on circuit
REPORT NO
069
1/12/20
Centrifugal Head noise
REPORT NO
068
1/11/20
Venous Reservoir disposable issue
REPORT NO
067
1/11/20
Failure of Heater Cooler due to leaking valves
REPORT NO
066
1/11/20
Failure of Valves on heater cooler unit
REPORT NO
065
1/9/20
Intra Aortic Balloon Pump (IABP) Failure
REPORT NO
064
1/9/20
Centrifugal head failure
REPORT NO
063
1/8/20
Centrifugal head issue 4
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?
Communication went well. Response to the problem was swift and acted upon quickly, thus preventing extra exposure to blood products. Even though the main people involved with this patients care were experienced senior staff, this was something which they all had not come across before and was therefore unexpected.
New action plans/changes as a result of the event?
No new action plans. The feedback to all members of the team and family were appreciated.