Archived Perfusion Report - 048

PERFUSION REPORTS

REPORT

048

DATE

1/8/2019

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

Select and scroll to view chosen report

VIEW
REPORT

REPORT NO

089



1/9/21

Sechrist Gas Blender Sweep on ECMO

VIEW
REPORT

REPORT NO

088



1/9/21

Oxygenator High Pressure Events

VIEW
REPORT

REPORT NO

087



1/10/21

Leaking one way valve

VIEW
REPORT

REPORT NO

086



1/7/21

Electronic Gas Blender Fault

VIEW
REPORT

REPORT NO

085



1/2/21

Protamine Administration Issue

VIEW
REPORT

REPORT NO

084



1/6/21

Damaged roller pump lid

VIEW
REPORT

REPORT NO

083



1/6/21

IABP malfunction

VIEW
REPORT

REPORT NO

082



1/1/21

Accidental cardioplegia administration

VIEW
REPORT

REPORT NO

081



1/4/21

S5 Double Roller Pump incident

VIEW
REPORT

REPORT NO

080



1/5/21

Human factors issue

VIEW
REPORT

REPORT NO

079



1/6/21

Centrimag battery module failure

VIEW
REPORT

REPORT NO

078



1/6/21

Sampling manifold valve fault

VIEW
REPORT

REPORT NO

077



1/5/21

IABP transport issue

VIEW
REPORT

REPORT NO

076



1/4/21

Modified Ultrafiltration (MUF) Issue

VIEW
REPORT

REPORT NO

075



1/3/21

Electromagnetic interference with HLM

VIEW
REPORT

REPORT NO

074



1/2/21

HCU40 Failure

VIEW
REPORT

REPORT NO

073



1/2/21

HCU40 valve failures

VIEW
REPORT

REPORT NO

072



1/1/21

HCU40 failure

VIEW
REPORT

REPORT NO

071



1/1/21

LIVA NOVA STATEMENT ON CENTRIFUGAL HEAD

VIEW
REPORT

REPORT NO

070



1/1/21

Loose component on circuit

VIEW
REPORT

REPORT NO

069



1/12/20

Centrifugal Head noise

VIEW
REPORT

REPORT NO

068



1/11/20

Venous Reservoir disposable issue

VIEW
REPORT

REPORT NO

067



1/11/20

Failure of Heater Cooler due to leaking valves

VIEW
REPORT

REPORT NO

066



1/11/20

Failure of Valves on heater cooler unit

VIEW
REPORT

REPORT NO

065



1/9/20

Intra Aortic Balloon Pump (IABP) Failure

VIEW
REPORT

REPORT NO

064



1/9/20

Centrifugal head failure

VIEW
REPORT

REPORT NO

063



1/8/20

Centrifugal head issue 4

VIEW
REPORT

REPORT NO

062



1/8/20

Human Factors Issue

VIEW
REPORT

REPORT NO

061



1/8/20

LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE

VIEW
REPORT

REPORT NO

060



1/8/20

Oxygenator Fibre Leak

Perfusion Report cards are shown in batches of 30 at any one time where available.

Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.

PERFUSION REPORTS

OTHER PERFUSION REPORTS

OTHER PERFUSION
REPORTS