PERFUSION REPORTS

REPORT

123

DATE

5/7/2024

TITLE

Hardware Fault

DETAILS OF INCIDENT

Duringa routine bypass case for isolated AVR the main roller pump suddenly stopped.The speed controller green LED indicator lights stayed at the previouslyindicated rpm level, the touchscreen was unresponsive.

This happened 3 times during the case at different intervals.

DETAILS OF INJURY TO PATIENT

No Harm

TYPE OF DEVICE/MANUFACTURER

LivaNova S5

‍

ACTION TAKEN

In the first instance the speed controller knob was quickly turned down to 0 rpm and then back up to the appropriate level, bypass was re-established with little delay. The same action was taken at the 2nd occurrence of the same issue. On the 3rd occurrence the single pump module was turned off and back on again, bypass was re-established, with no subsequent recurrence, the patient was separated from bypass at the conclusion of the surgery without incident. The pump module was then taken out of service, and the manufacturer informed.

‍

RESPONSE FROM MANUFACTURER

LivaNova interrogated the pump history and decided that the cause was a fault in the touchscreen, which was duly replaced. It was put back in service and has been functioning normally since then.

‍

ADDTIONAL INFORMATION

The safety committee reviewed the incident. It is essential as part of the QMF that equipment is maintained and serviced and faults communicated. We thanks the reporter for highlighting this issue.

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

062



1/8/20

Human Factors Issue

REPORT NO

061



1/8/20

LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE

REPORT NO

060



1/8/20

Oxygenator Fibre Leak

REPORT NO

059



1/5/20

Failure to remove CO2 effectively

REPORT NO

058



1/7/20

Centrifugal Head Issue 3

REPORT NO

057



1/6/20

Centrifugal Head Issue 2

REPORT NO

056



1/1/20

Centrifugal Head Issue

REPORT NO

055



1/2/20

Faulty Pressure Relief Valves

REPORT NO

054



1/4/20

Leaking ALF

REPORT NO

053



1/2/20

Arterial Line Filter Leak

REPORT NO

052



1/3/19

Gas Line Filter Issue

REPORT NO

051



1/12/19

Dual Lumen Cannula Movement

REPORT NO

050



1/10/19

Venous Cannula Damaged

REPORT NO

049



1/12/19

Oxygenation Issue

REPORT NO

048



1/8/19

Roller Pump Failure

REPORT NO

047



1/12/19

Broken Cannula Dilator

REPORT NO

046



6/12/19

Gas Blender Error

REPORT NO

045



20/11/19

Tubing Detachments

REPORT NO

044



27/11/19

Interruption to IABP counterpulsation

REPORT NO

043



1/7/19

Getinge Mal-Position Of IABP Catheter

REPORT NO

042



1/2/19

Avalon Dual Lumen Cannula Crack

REPORT NO

041



1/2/19

Custodial Rubber Fragmentation In Spiked Bag

REPORT NO

040



1/10/18

Reservoir Clot

REPORT NO

039



1/10/18

Pall Clot In Cardioplegia Circuit

REPORT NO

038



1/10/18

Maquet HL20 Cardioplegia Pump Error

REPORT NO

037



1/10/17

Temed D200 Haemoconcentrator Clot

REPORT NO

036



1/10/17

Oxygenator issue

REPORT NO

035



1/10/17

Medtronic Fusion Oxygenator Blood To Gas Leak

REPORT NO

034



Possible Medtronic Fusion Oxygenator Failure

REPORT NO

033



Fannin Heparin Ampules Shattering

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