REPORT
069
DATE
June 2021
TITLE
Sampling manifold valve fault
DETAILS OF INCIDENT

On CPB, the flow through the manifold samples line was severely restricted. It was noticed during administration through the line as it was easy to see clear fluid flowing extremely slowly along the line.

Also, the temperature read by the CDI monitoring was affected, with readings of around 6degrees Celsius lower than the actual one, with effects on pH stat values.

By removing the one way valve, all issues were resolved promptly.

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Dideco D101 Neonatal and Paediatric Set

ACTION TAKEN

All staff informed and warned to check for same issues. One way valve kept and packaged for return to manufacturer.

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION
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
077
DATE
Sep 2021
Sechrist Gas Blender Sweep on ECMO
REPORT NO
076
DATE
Sep 2021
Oxygenator High Pressure Events
REPORT NO
075
DATE
Oct 2021
Leaking one way valve
REPORT NO
074
DATE
July 2021
Electronic Gas Blender Fault
REPORT NO
073
DATE
February 2021
Protamine Administration Issue
REPORT NO
072
DATE
June 2021
Damaged roller pump lid
REPORT NO
071
DATE
June 2021
IABP malfunction
REPORT NO
070
DATE
Jan 2021
Accidental cardioplegia administration
REPORT NO
069
DATE
June 2021
Sampling manifold valve fault
REPORT NO
068
DATE
May 2021
Human factors issue
REPORT NO
067
DATE
June 2021
Centrimag battery module failure
REPORT NO
066
DATE
April 2021
S5 Double Roller Pump incident
BACK TO SAFETY ARCHIVE