PERFUSION REPORTS

REPORT
123
DATE
1/10/2024
TITLE
HCU/ Hardware incident/ Human Factors
DETAILS OF INCIDENT

During re-warming it was noted by the Perfusionist that the Heater/Cooler was not working and that the Perfusionist was unable to re-warm the patient. Another Perfusionist was called into theatre to swap out the defective device. The issue was diagnosed as a pump failure as there was no flow of water through the device. During the changeover of the Heater/Coolers, a kink in the water line was noticed and identified as the cause of the problem with the originalHeater/Cooler. The device was then reconnected to the oxygenator and to the cardioplegia heat exchanger. However, one of the cardioplegia heat exchanger lines was not attached and when the Heater/Cooler pumps were turned back on,water from the Heater/Cooler sprayed into the sterile field contaminating the wound, instruments and staff.

DETAILS OF INJURY TO PATIENT
TYPE OF DEVICE/MANUFACTURER
ACTION TAKEN

Medicalstaff made aware

Surgeon made aware

Microbiology informed and advice given. The heater cooler was tested on 12/09/2024 and was clear of chimera, on advice of the microbiologist at the Freeman it was immediately tested within one hour of said incident and was also clear. Chest washed out with tauraline. Surgical fields redrapped. Pravenna vacum dressing applied

 

The heater cooler itself was in no way at fault and all connection were secure it was user error and one connection was not attached when turned on, and the excess water within the lines sprayed into the surgical field. Since this incident we have added an emergency change out of a heater cooler while on bypass into our emergency protocols.

 

Datix submitted

 

Societyinformed

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION
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