OTHER PERFUSION
REPORTS
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REPORT NO
123
5/7/24
Hardware Fault
REPORT NO
122
5/4/24
Oxygenator Failure
REPORT NO
121
8/3/24
Disposables: Eurosets Adult ECMO Oxygenator
REPORT NO
120
1/5/24
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
110
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
Perfusion Report cards are shown in batches of 30 at any one time where available.
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Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.
The ECMO programme is relatively in its infancy and has only been recently given commissioned status. The reporting perfusionist found out that the patient was being mobilised without a perfusionist or perfusion team awareness incidentally upon reviewing notes when patient was ready for decannulation. ECMO is 5 floors away from Perfusion "home-base".
Usually patients are moved to CT/ retrieved across hospitals with a perfusionist and this would be one of 2 patients that have been awake on ECMO at the hospital. There was no communication from the intensivists and when raised as a problem, the intensivist said the patient was being mobilised for a week, and was owing to the physiotherapist's team eagerness to mobilise the patient. I felt that this plan forewent the safety aspect of ECMO.
This has been reported to the Perfusion ECMO lead and ongoing matter.
The safety committee are liaising with the reporter and will work with the hospital to review processes.