Welcome to the Web Reports Page.

Web Reports are taken from the Safety Committee web based reporting system and after appropriate anonymising disseminated to the membership. The content should be informative and hopefully encourage similar sharing from the perfusion community.

Details of incident/Nature of defect:

Trainee Perfusionist added an extra sucker to a pre built circuit & failed to complete the 3 perfusion sucker checks. The 4th and final sucker check, a visual wet test of the suckers with the scrub nurse was only completed for 2 of the 3 suckers i.e. not the additional sucker.

The additional sucker was used as a vent and after x clamping the surgeon asked for the vent to be turned on and noted it was blowing not sucking, this was switched off and corrected. The surgeon was adamant that the Aorta was X clamped before the vent was switched on and that no air entered the patient.

Details of injury (to patient/healthcare professional):

Post operatively the patient showed Lt sided stroke and the family was informed of the incident involving the reversed suction tubing.

The patient and family have been kept fully informed as to the possible reasons for the stroke - and that stroke is a known risk from cardiac surgery and cardiopulmonary bypass.

The family has also been kept fully informed of the mistakes made during setup and checking of the suckers.


Action taken (includes any action by patient, carer or healthcare professional or by the manufacturer or supplier):

A Hospital Incident Report was filed on the day of the incident. A panel met and discussed the incident and decided to conduct a full SUI investigation with outcome of investigation sent to family and the SHA.

A full review of practices has been undertaken, this has resulted in a number of changes to procedure and/or protocols.

Details of incident/Nature of defect:

Patient commenced on cardiopulmonary bypass, flow/line pressure normal, on bypass just over 1 minute venous blood appeared very blue as did arterial blood, had just cross clamped and cardioplegia just running, informed surgeon and anaesthetist problem with blood gas blender. FiO2 at 60%, and gas flow at 2.5L, on commencing bypass. Adjusted FiO2 to 100%, and gas flow to 10L, palpated end of air/O2 line with finger, very little air/O2 going into oxygenator. Traced line back to vaporiser, large tear observed on tubing at back of he vaporiser, line seemed perished. Anaesthetist put tape/sleek on tubing and a tie wrap, which solved problem. Poor oxygenation for over 2minutes, blood gases were pO2=6.7kPa, PCO2=6.8kPa. Repeat blood gases after the repair were PO2=53.2kPa, PCO2=7.2kPa. Adjusted FiO2 and gas flow then repeated blood gases were PO2=29.6kPa, PCO2=4.5kPa. Case continued without incident, exited CPB without problem.

Details of injury (to patient/healthcare professional):

None.


Action taken (includes any action by patient, carer or healthcare professional or by the manufacturer or supplier):

Replaced defective tubing, must replace/check tubing more frequently.

Details of incident/Nature of defect:

Gas blender flow control knob jammed no flow of gas possible. Perfusionist dis-assembled the knob and could manipulate the flow with a tubing clamp. Having been serviced this subsequently occurred a second time on the device which was only 6 months old. Device returned to manufacturer for a full overhaul and is back in service.


Details of injury (to patient/healthcare professional):

None.


Action taken (includes any action by patient, carer or healthcare professional or by the manufacturer or supplier):

Device returned to manufacturer for overhaul. All perfusionists alerted how to avoid and dis-assemble this device if event re-occurs. Other methods of gas supply are currently available in operating room.

Details of incident/Nature of defect:

An Isoflurane vaporiser was full and on a hanger suspended from a vertical pole. The vaporiser was allowed to rest on the base of the pump console. This caused the vaporiser seals to leak causing a reduction of flow. An unusually high flow rate was necessary to maintain normal blood gases to the patient. Once the vaporiser was repositioned without touching the base no further problems were encountered.


Details of injury (to patient/healthcare professional):

None.


Action taken (includes any action by patient, carer or healthcare professional or by the manufacturer or supplier):

Vaporisers should not be allowed to touch the base of the console if suspended from a hanger pole due to the possibilities of gas leakages from the seals. This has been reported in the anaesthetic journals.