PERFUSION REPORTS

REPORT

094

DATE

1/11/2021

TITLE

Oxygenation failure upon commencement of CPB

DETAILS OF INCIDENT

Oxygenation failure upon commencement of bypass. A crack was identifed on the 1/4" straight connector with luer within the gas delivery line. This connector is used to transduce the gas delivery pressure.

Prebypass checks were in place and performed to verify gas delivery to oxygenator.

Connector damage possibly occurred as a result of moving equipment passing the HLM during this emergency procedure.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

n/a

ACTION TAKEN

Immediate actions were to re-ventilate the patient and terminate CPB. Cause of oxygenation failure was identified and rectified, CPB was recommenced. No harm was caused to patient.

After departmental consultation, it was agreed to remove the gas delivery pressure monitoring (1/4" connector with luer lock) to prevent the potential for future occurence.

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
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

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

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

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REPORT NO

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

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REPORT NO

105



9/9/22

Issue with use of disposable

REPORT NO

104



13/6/22

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REPORT NO

103



25/7/22

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REPORT NO

102



7/7/22

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REPORT NO

101



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REPORT NO

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

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

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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

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

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REPORT NO

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

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Protamine Administration

REPORT NO

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

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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