REPORT
034
DATE
06-12-2019
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
044
DATE
Jan 2020
Centrifugal Head Issue
REPORT NO
043
DATE
Feb 2020
Faulty Pressure Relief Valves
REPORT NO
042
DATE
Apr 2020
Leaking ALF
REPORT NO
041
DATE
Feb 2020
Arterial Line Filter Leak
REPORT NO
040
DATE
Mar 2019
Gas Line Filter Issue
REPORT NO
039
DATE
Dec 2019
Dual Lumen Cannula Movement
REPORT NO
038
DATE
Oct 2019
Venous Cannula Damaged
REPORT NO
037
DATE
Dec 2019
Oxygenation Issue
REPORT NO
036
DATE
Aug 2019
Roller Pump Failure
REPORT NO
035
DATE
Dec 2019
Broken Cannula Dilator
REPORT NO
034
DATE
06-12-2019
Gas Blender Error
REPORT NO
033
DATE
20-11-2019
Tubing Detachments
BACK TO SAFETY ARCHIVE