PERFUSION REPORTS

REPORT

111

DATE

10/2/2023

TITLE

Human Factors

DETAILS OF INCIDENT

An FiO2 monitor had been removed from a set-up bypass machine due to failure.

A replacement was not put in place.

Bypass machine was used on patient and air escaped through the open port that should have had the FiO2 monitor in place.

The gas pathway had been checked prior to bypass, but it had not been noticed that the FiO2 monitor was absent.

Upon bypass initiation the venous saturations dropped but not immediately as there must have still been a small delivery of gas.

Once they dropped and it was noted that the blood was dark in colour, bypass was terminated, ventilation was restarted.

The FiO2 monitor was found to be missing and replaced. Bypass was re-initiated and the operation was completed successfully.

‍

DETAILS OF INJURY TO PATIENT

TYPE OF DEVICE/MANUFACTURER

ACTION TAKEN

The Department amended their prebypass checklist to include the full gas pathway check including the presence of FiO2 monitor.

They also now as part of the maintenance form include that a replacement has been put in place when the defected item is removed.

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

The safety committee has reviewed this incident and the transparency demonstrates that human error can be commonplace and how important effective checklists and engagement is. The new check list will ensure this error can be mitigated, although it must be acknowledged that even with checklists error can happen due to human factors. We would encourage all incidents to consider the human factors that may have led to incidents for review and analysis.

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

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

Perfusion Report cards are shown in batches of 30 at any one time where available.

123

122

121

120

119

118

117

116

115

114

112

111

110

109

108

107

106

105

104

103

102

101

100

099

098

097

096

095

094

093

092

091

090

089

088

087

086

085

084

083

082

081

080

079

078

077

076

075

074

073

072

071

070

069

068

067

066

065

064

063

062

061

060

059

058

057

056

055

054

053

052

051

050

049

048

047

046

045

044

043

042

041

040

039

038

037

036

035

034

033

032

031

030

029

028

027

026

025

024

023

Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.

USEFUL LINKS

BACK TO SAFETY ARCHIVE SAFETY - SUBMIT A REPORT SAFETY COMMITTEE SAFETY CONTACTS

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Copyright © 2024. The Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland.

DMCA.com Protection Status

Made With  By MojoPixels‍