PERFUSION REPORTS

REPORT

130

DATE

19/5/2025

TITLE

Hardware: Level Alarm

DETAILS OF INCIDENT

Patient ready to go on cardiopulmonary bypass. Heart lung machine which had passed all safety checks was already connected to the patient. Level alarm (critical alarm) had a sensor malfunction. Despite numerous attempts to reset the alarm to allow bypass to continue, the malfunction persisted.

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DETAILS OF INJURY TO PATIENT

A decision was made to disconnect patient from HLM and use an alternative machine. Consultant surgeon and consultant anaesthetist informed, and new HLM and circuit obtained from perfusion, new circuit primed, checked and connected to patient and successfully placed on bypass. There was a delay of approximately 15 minutes. Patient was stable throughout.

TYPE OF DEVICE/MANUFACTURER

Spectrum contacted and Datex report submitted.

Model: Serial No: QLV1000397

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ACTION TAKEN

A decision was made to disconnect patient from HLM and use an alternative machine. Consultant surgeon and consultant anaesthetist informed, and new HLM and circuit obtained from perfusion, new circuit primed, checked and connected to patient and successfully placed on bypass. There was a delay of approximately 15 minutes. Patient was stable throughout.

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RESPONSE FROM MANUFACTURER

The result of the investigation is that it wascaused by suspected damaged wiring or solder connection going into or insidethe red protected level sensor which caused the fault.

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ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

https://eu-files.jotform.com/jufs/Perfusionadmin/91872635781367/6235366567124154539/d650d6bd-63aa-468e-a126-f422f7e26912.jpeg?md5=QfTpwfFwTugY8_gIOFpwzQ&expires=1761920854

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