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
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.