PERFUSION REPORTS

REPORT
104
DATE
13/6/2022
TITLE
Human Factors
DETAILS OF INCIDENT

Initial failures to deliver cardioplegia - asystole not reached after 600ml.

Subsequently noticed that cardioplegia line had been left out of the raceway (cold blood only administered) - checklist failure!

Immediate action was taken to engage the cardioplegia raceway and continue with 4:1 blood cardioplegia delivery, asystole was achieved after 200ml.

DETAILS OF INJURY TO PATIENT

NO injury or harm was caused as a result of this event.

TYPE OF DEVICE/MANUFACTURER

n/a

ACTION TAKEN

As above

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION
 REPORTS

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REPORT NO
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REPORT NO
121
8/3/24
Disposables: Eurosets Adult ECMO Oxygenator
REPORT NO
120
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Disposable Incident
REPORT NO
119
Hardware: HCU Contamination
REPORT NO
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
REPORT NO
112
20/2/23
HLM Hardware Error: S5 HLM - Dual roller cardioplegia
REPORT NO
111
10/2/23
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
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