OTHER PERFUSION
REPORTS
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REPORT NO
003
1/2/10
Difficulties In Visualising Blender Reading
REPORT NO
002
1/1/10
Luer Cap Found In Venous Inlet Port
REPORT NO
001
1/1/09
Oxygenator Water To Blood Leak
Perfusion Report cards are shown in batches of 30 at any one time where available.
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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.