PERFUSION REPORTS

REPORT
127
DATE
4/1/2025
TITLE
Eurosets Oxygenator leak
DETAILS OF INCIDENT

Eurosets oxy leak  

 

 

Preprimed  emergency pump (primed Friday 29th March).  

Put in theatre  for scheduled root and hemiarch on 1/04/2025.

Very large leak,  possibly after water lines turned on but fluid in gas line and strong stream  at gas escape.

Oxy change  before surgery.  

No impact on  patient or delay.  

Made easier by  perfusion team numbers (three staff during changeout made it quicker)

    

Pre-primed pumps have a water  circuit pressure check with a homemade positive pressure tester which is  recorded on our checklist laminate. Incident shared with perfusion team to  re-enforce checks if necessary. Awaiting assessment from supplier

 

DETAILS OF INJURY TO PATIENT
TYPE OF DEVICE/MANUFACTURER

Eurosets A.L one plus oxygenator: AG5204: 010669209

ACTION TAKEN

Change out and report to suppliers. Incident sharing within team and with MHRA and Society.

RESPONSE FROM MANUFACTURER

MHRA and Eurosets informed. Awaiting Response.

ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION
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REPORT NO
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REPORT NO
108
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Perfusion Report cards are shown in batches of 30 at any one time where available.
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