PERFUSION REPORTS

REPORT

067

DATE

1/11/2020

TITLE

Failure of Heater Cooler due to leaking valves

DETAILS OF INCIDENT

I received a call out of hours from a member of theatre staff, the HCU40 in cardiac theatres was alarming "power failure" and sparks were seen coming from the bottom of the device. I advised the nurse to switch off the HCU.

There had been 2 Field Safety Notices issued in recent months recommending replacement of valves and crimping of power cables, however the recommendation in the safety notice had been to continue use as normal.

(Please see picture attached in additional information)

(Please see FSN 028)

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Getinge HCU40

ACTION TAKEN

The next day the unit was removed from service, the engineer was informed and a repair/replacment was arranged.

The unit valves were replaced and the unit was put back into service.

‍

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

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