OTHER PERFUSION
REPORTS
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REPORT NO
020
S3 E62 Pump Error
REPORT NO
019
Medtronic Potential Oxygenator Leak
REPORT NO
018
Medos Heat Exchanger Leak
REPORT NO
017
Avant D903 Has A Dual Chamber Reservoir Leak
REPORT NO
016
Additional Sucker Incorrectly Placed In Raceway
REPORT NO
015
Large Perished Tear Observed On Tubing At Back Of Vaporiser
REPORT NO
014
Gas Blender Flow Control Immobilised
REPORT NO
013
Isoflurane Vaporiser Seal Leak Due To Malposition
REPORT NO
012
1/2/13
Hypercoagulable Disorder May Have Led To Oxygenator Failure
REPORT NO
011
1/1/13
LV Vent Placed In Raceway In Wrong Direction
REPORT NO
010
1/3/12
Sucker Placed In Raceway In Wrong Direction
REPORT NO
009
1/2/12
Similarity In Heparin And St Thomas Cardioplegia Ampules
REPORT NO
008
1/7/11
Aorta Remained Clamped Post CPB
REPORT NO
007
1/5/11
Deficiencies In The QC At Terumo Ann Arbor, USA.
REPORT NO
006
1/4/11
Awareness Of Suckers When Using Bio-Glues
REPORT NO
005
1/2/11
Patient Exsanguinated From Additional Venous Line Post CPB
REPORT NO
004
1/1/11
Possible Inaccuracies In Colloid Research
REPORT NO
003
1/2/10
Difficulties In Visualising Blender Reading
REPORT NO
002
1/1/10
Luer Cap Found In Venous Inlet Port
REPORT NO
001
1/1/09
Oxygenator Water To Blood Leak
Perfusion Report cards are shown in batches of 30 at any one time where available.
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Full Patient Level Safety Report was carried out. On investigation, nothing was found to be wrong with the vaporiser or the bracket.
This is a design fault with the bracket made by G.A.S (General Anaesthetic Services). I understand this does not have CE marking as I have tried to buy replacements, but cannot do so. MHRA not contacted as there was no fault found.
Presented this case at the safety committee session at the annual congress in Nottingham 2025.