REPORT
036
DATE
Aug 2019
TITLE
Roller Pump Failure
DETAILS OF INCIDENT

50 minutes into cardiopulmonary bypass for a routine CABG the main arterial roller pump stopped abruptly and the malfunction alarm appeared on the control mast.  The pump was rebooted with no response.  

Hand cranking was commenced at this point.  The pump was powered down again and rebooted, this corrected the malfunction alarm.  

Cardiopulmonary bypass was restarted with no further issues.  

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Stockert S5

ACTION TAKEN

The pump was examined and serviced by Liva Nova and a report was raised. No issues or faults were detected-it was likely a software issue.

An incident report was submitted to risk management.

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

Upon reflection what do you think went well?

Staff went through the correct steps and emergency procedures to rectify the problem in a timely fashion.  

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

Pumps are due for replacement later this year.  

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