PERFUSION REPORTS

REPORT

062

DATE

1/8/2020

TITLE

Human Factors Issue

DETAILS OF INCIDENT

Interruption of circuit set up and priming due to time constraints (trying to finish ahead of anaesthesia in order to leave the room due to COVID airways protocol). Normal cue to add monitoring device disposable into circuit lost (added after circuit finished). Checklist item too non-specific - "arteral CDI calibrated".

CDI was assumed to be in circuit and functional throughout case - calibrated with each gas. Error only noticed after warm gas with low pO2 of 7.8kPa despite a CDI value of 27. FIO2 increase resolved the arterial saturation drop that was noticed on anaesthetic monitor.

DETAILS OF INJURY TO PATIENT

No injuries were noted to have occurred to the patient.

TYPE OF DEVICE/MANUFACTURER

Terumo CDI Sensor

ACTION TAKEN

- The checklist has been changed from "CDI calibrated" which was deemed to be a poor cue to ensure it was connected to the circuit, to CDI connected to circuit.

- It was reported to other members of the team to highlight the potential of its omission -some had made a similar mistake previously.

- The department is looking at a way of improving in-house problem solving and reporting after this incident. The department are currently using apps on mobile devices where if anything challenges the normal work flow it can be logged via phone in a word or two in a matter of seconds. This allows for increased visibility for all and for the safety team to follow up any events.

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

n/a

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

032



Sucker Placed In Raceway In Wrong Direction

REPORT NO

031



High Transmembrane Pressure Gradients

REPORT NO

030



Faulty Connector On ECMO Soft Shell Reservoir Bag

REPORT NO

029



Sorin Inspire 8F Blood Leak From Temperature Port

REPORT NO

028



Sorin Inspire 8F Oxygenator Detached From Holding Arm

REPORT NO

027



Paragon Oxygenator Gas Inlet Leak

REPORT NO

026



Maquet IABP Console Failure

REPORT NO

025



Sorin EOS Gas To Blood Leak Whilst Priming

REPORT NO

024



Chalice Paragon Midi Heat Exchanger Leak Whilst Priming

REPORT NO

023



Chalice Paragon Heat Exchanger Water To Blood Leak

REPORT NO

022



Vent Pump Boot Tubing Inserted In Wrong Way Round

REPORT NO

021



Paragon Oxygenator Heat Exchanger Leak

REPORT NO

020



S3 E62 Pump Error

REPORT NO

019



Medtronic Potential Oxygenator Leak

REPORT NO

018



Medos Heat Exchanger Leak

REPORT NO

017



Avant D903 Has A Dual Chamber Reservoir Leak

REPORT NO

016



Additional Sucker Incorrectly Placed In Raceway

REPORT NO

015



Large Perished Tear Observed On Tubing At Back Of Vaporiser

REPORT NO

014



Gas Blender Flow Control Immobilised

REPORT NO

013



Isoflurane Vaporiser Seal Leak Due To Malposition

REPORT NO

012



1/2/13

Hypercoagulable Disorder May Have Led To Oxygenator Failure

REPORT NO

011



1/1/13

LV Vent Placed In Raceway In Wrong Direction

REPORT NO

010



1/3/12

Sucker Placed In Raceway In Wrong Direction

REPORT NO

009



1/2/12

Similarity In Heparin And St Thomas Cardioplegia Ampules

REPORT NO

008



1/7/11

Aorta Remained Clamped Post CPB

REPORT NO

007



1/5/11

Deficiencies In The QC At Terumo Ann Arbor, USA.

REPORT NO

006



1/4/11

Awareness Of Suckers When Using Bio-Glues

REPORT NO

005



1/2/11

Patient Exsanguinated From Additional Venous Line Post CPB

REPORT NO

004



1/1/11

Possible Inaccuracies In Colloid Research

REPORT NO

003



1/2/10

Difficulties In Visualising Blender Reading

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