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

London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Select and scroll to view chosen report
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.
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
London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.