PERFUSION REPORTS

REPORT
046
DATE
6/12/2019
TITLE
Gas Blender Error
DETAILS OF INCIDENT

There was an electronic Gas Blender Error – Code E19, in the preoperative period.  

The error code appeared continually on the electronic blender without an audible alarm from the blender itself.  There was however a continual audible and visual alarm from the system display module.  

When the error message was displayed, there was still flow through the oxygen tubing and oxygen concentration had not been affected, however the error message remained and could not be reset.  

This alarm is not referred to in the manufacturers manual.  

DETAILS OF INJURY TO PATIENT

None as the incident occurred preoperatively

TYPE OF DEVICE/MANUFACTURER

Stockert Electronic Blender with S5

ACTION TAKEN

The electronic gas blender was switched out for another blender.  

The control panel that controlled the gas blender also controlled the heater cooler unit.  The heater cooler controls were still functioning, however the module was changed out to rule out a module issue but the same fault was still displayed. The faulty blender was removed from the department and sent to Liva Nova for inspection.  

RESPONSE FROM MANUFACTURER

None yet received.

ADDTIONAL INFORMATION

Upon reflection what do you think went well?

The affected gas blender was changed out without any issue.  

New action plans/changes as a result of the event?

None

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
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
REPORT NO
092
1/10/21
Vapourizer Issue
REPORT NO
091
1/10/21
Oyxgenator Leak
REPORT NO
090
1/10/21
Breach of chemical cleaner
Perfusion Report cards are shown in batches of 30 at any one time where available.
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
022
021
020
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.