PERFUSION REPORTS

REPORT

082

DATE

1/1/2021

TITLE

Accidental cardioplegia administration

DETAILS OF INCIDENT

Whilst flushing the cardioplegia circuit on a paediatric case a team member bringing in a piece of hardware ( not requested at a team brief) struggled sufficiently so as to distract the perfusionist running the bypass long enough to flush almost a whole bag of cardioplegia into the bypass circuit.

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This case has been published in Anaesthesia Reports and is available to read at:

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1002/anr3.12111

DETAILS OF INJURY TO PATIENT

n/a

TYPE OF DEVICE/MANUFACTURER

n/a

ACTION TAKEN

As described in published paper

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

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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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