PERFUSION REPORTS

REPORT

078

DATE

1/6/2021

TITLE

Sampling manifold valve fault

DETAILS OF INCIDENT

On CPB, the flow through the manifold samples line was severely restricted. It was noticed during administration through the line as it was easy to see clear fluid flowing extremely slowly along the line.

Also, the temperature read by the CDI monitoring was affected, with readings of around 6degrees Celsius lower than the actual one, with effects on pH stat values.

By removing the one way valve, all issues were resolved promptly.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Dideco D101 Neonatal and Paediatric Set

ACTION TAKEN

All staff informed and warned to check for same issues. One way valve kept and packaged for return to manufacturer.

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

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Detached bullet tip of sump-updated response Sep 2022

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