PERFUSION REPORTS

REPORT

130

DATE

19/5/2025

TITLE

Hardware: Level Alarm

DETAILS OF INCIDENT

Patient ready to go onto cardiopulmonary bypass and 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

No injury, patient remained stable throughout.

TYPE OF DEVICE/MANUFACTURER

Spectrum HLM

Model: Serial No: QLV1000397

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ACTION TAKEN

A decision was made to disconnect the patient from the HLM and use an alternative machine. Consultant surgeon and consultant anaesthetist were informed, and a new HLM and circuit obtained from perfusion. The new circuit was primed, checked and connected to the patient who was then successfully placed onto bypass. There was a delay of approximately 15 minutes. Patient was stable throughout. Spectrum were contacted and a Datix report was submitted.

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RESPONSE FROM MANUFACTURER

The result of the investigation showed that it was caused by suspected damaged wiring or solder connection going into, or inside the red protected level sensor which caused the fault.

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ADDTIONAL INFORMATION

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

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