PERFUSION REPORTS

REPORT
125
DATE
11/2/2025
TITLE
Hardware Error: Bubble Detector
DETAILS OF INCIDENT

While on bypass with a warm patient post XC removal the bubble detector alarmed and the alarm could not be cleared. This occured on a centrifugal pump, so the ERC automatically clamped the arterial line. As the alarm could not be cleared the ERC would not open.

DETAILS OF INJURY TO PATIENT
TYPE OF DEVICE/MANUFACTURER
ACTION TAKEN

The Arterial line was checked for air, none was found. The alarm could not be cleared. The bubble detector was moved to a different point along the tubing and the alarm could still not be cleared. The bubble alarm was turned off and on twice without resolution. Hand cranking took place while a colleague was called to assist. Colleague switched off the alarm, moved the pump from hand crank back into the motor and successfully went back on bypass. The bubble alarm was turned back on after about 5 minutes when the patient was stable. No more issues.

RESPONSE FROM MANUFACTURER
ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

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