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
002
1/1/10
Luer Cap Found In Venous Inlet Port
REPORT NO
001
1/1/09
Oxygenator Water To Blood Leak
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