PERFUSION REPORTS

REPORT
044
DATE
27/11/2019
TITLE
Interruption to IABP counterpulsation
DETAILS OF INCIDENT

There was an interruption to IABP counter pulsation therapy out of hours. On arrival, alarm message was displayed "failure to pump". The gas line was inspected with no obstruction. Several attempts at re-institution of therapy were made unsuccessfully. A change of console was carried out and therapy was recommenced.

DETAILS OF INJURY TO PATIENT

Interruption to counter pulsation with IABP in standby for approximately 50 minutes.

TYPE OF DEVICE/MANUFACTURER

Getinge Cardiosave Hybrid

ACTION TAKEN

On arrival of the on-call Clinical Perfusion Scientist, the console was changed out and therapy was recommenced. It was not deemed appropriate/necessary to change IAB catheter.

The affected console was taken out of service and repaired. It was noted post service that it was a failure of the safety disk.

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

Upon reflection what do you think went well?

The on-call Clinical Perfusion Scientist arrived promptly (approx 30 mins out of hours) and the console was changed out quickly with no issues.

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

A teaching session with senior intensive care nursing staff (zone leaders) on troubleshooting and demystifying the IABP console to be arranged.

Troubleshooting flow charts have been added to the consoles to try minimise any downtime in patient therapy, should interruption occur. It is intended to have annual refreshers for this group of staff.

MHRA Informed

SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

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