PERFUSION REPORTS

REPORT

129

DATE

3/5/2025

TITLE

Human Factors

DETAILS OF INCIDENT

A patient was transferred on central VA ECMO from critical care to theatre. Piped gas was replaced by an oxygen cylinder for transfer. Upon arriving in theatre the ECMO console alarmed low flow and distracted the perfusionist during plugging the ECMO into mains and swapping the oxygen cylinder for piped gas. It was noted some time later that the patient's pO2 was low on an ABG, and the ECMO lines were dark. It was then noted that the ECMO had been left connected to the oxygen cylinder which had run out.

Immediate action: ECMO connected to piped gas. Pupils checked by anaesthetist and noted to be ok. Patient woke up fine with no harm.

Distraction due to an alarm while transferring gas supply led to human error of one step being missed in the process of connecting to piped gas. Patient woke up and is OK, however, further mitigations are required to reduce the impact of human error.

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DETAILS OF INJURY TO PATIENT

TYPE OF DEVICE/MANUFACTURER

ACTION TAKEN

This incident has been added as a risk to the risk register with the following 3 actions:

- Improve the transfer checklist.

- Investigate the option of using oxygen cylinders with low oxygen alarms.

- New ECMO hardware/circuits are planned to be purchased int he future. There are systems on the market that have built in saturation monitoring. It would be ideal if saturation monitoring was a minimum requirement for any new ECMO systems.

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RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

An excellent review and response to a human factor failure that could impact patient care.

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