PERFUSION REPORTS

REPORT

068

DATE

1/11/2020

TITLE

Venous Reservoir disposable issue

DETAILS OF INCIDENT

Whilst dismantling the bypass circuit for disposal I lifted the venous reservoir off its holder using the venous inlet connector which became detached with little force applied.

I was able to reposition the sealing washer and reattach (clip) the venous column back into the reservoir with ease but it felt just too easy to pull off and on.

(Please see picture in additional information)

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Medtronic Affinity Fusion Venous Reservoir

‍

ACTION TAKEN

Manufacturer informed and the rest of the perfusion department informed.

Decision taken to stop using that batch until further details are received from Medtronic QA

RESPONSE FROM MANUFACTURER

Waiting on response.

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

Please see picture attached

SUPPORTING DOCUMENT

Venous reservoir picture

Manufacturers Report

OTHER PERFUSION
REPORTS

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REPORT NO

123

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REPORT NO

122



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Oxygenator Failure

REPORT NO

121



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120



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119



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118



12/9/23

Human Factors: ECMO Mobilisation

REPORT NO

117



27/9/23

Disposables: Oxygenator

REPORT NO

116



14/9/23

Disposable Issue: Reservoir in CPB circuit

REPORT NO

115



13/9/23

Disposable Error

REPORT NO

114



13/7/23

Dispoables

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

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HLM Hardware Error: S5 HLM - Dual roller cardioplegia

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

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Human Factors

REPORT NO

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

31/1/23

DISPOSABLE FAULT

REPORT NO

109



19/1/23

Disposable issue

REPORT NO

108



3/1/23

Disposable issue: Oxygenator leak

REPORT NO

107



6/12/22

Hardware fault. Electronic gas Blender failure

REPORT NO

106



1/11/22

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



6/4/21

Irregular blood flow/foreign looking substance in Oxygenator

REPORT NO

100



20/4/22

Gas Line Filter Fault

REPORT NO

099



20/4/22

Human Factors: BiVAD Error

REPORT NO

098



4/4/22

REPORT NO

097



19/3/22

Disposables Issue

REPORT NO

096



18/3/22

Bubbles Sensor Activation

REPORT NO

095



1/1/22

Protamine Administration

REPORT NO

094



1/11/21

Oxygenation failure upon commencement of CPB

REPORT NO

093



1/11/21

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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