PERFUSION REPORTS

REPORT

067

DATE

1/11/2020

TITLE

Failure of Heater Cooler due to leaking valves

DETAILS OF INCIDENT

I received a call out of hours from a member of theatre staff, the HCU40 in cardiac theatres was alarming "power failure" and sparks were seen coming from the bottom of the device. I advised the nurse to switch off the HCU.

There had been 2 Field Safety Notices issued in recent months recommending replacement of valves and crimping of power cables, however the recommendation in the safety notice had been to continue use as normal.

(Please see picture attached in additional information)

(Please see FSN 028)

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Getinge HCU40

ACTION TAKEN

The next day the unit was removed from service, the engineer was informed and a repair/replacment was arranged.

The unit valves were replaced and the unit was put back into service.

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RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
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108



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REPORT NO

107



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Hardware fault. Electronic gas Blender failure

REPORT NO

106



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ECG Interference

REPORT NO

105



9/9/22

Issue with use of disposable

REPORT NO

104



13/6/22

Human Factors

REPORT NO

103



25/7/22

Human Factors

REPORT NO

102



7/7/22

Disposable issue

REPORT NO

101



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REPORT NO

100



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REPORT NO

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

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REPORT NO

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

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REPORT NO

097



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REPORT NO

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

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REPORT NO

095



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Protamine Administration

REPORT NO

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

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REPORT NO

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

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Detached bullet tip of sump-updated response Sep 2022

Perfusion Report cards are shown in batches of 30 at any one time where available.

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