PERFUSION REPORTS

REPORT

144

DATE

29/7/2026

TITLE

Oxygen sensor

DETAILS OF INCIDENT

The sensor had a leak at its connection site. Whilst it still read the called for percentage of oxygen, it did not identify the significalnt reduction in flow. This was extremely misleading as it's use in identifying a cause for extreme hypercapnia resulted in suspicion of oxygenator failure. As a side note this happened 3 times before the root cause was identified.

DETAILS OF INJURY TO PATIENT

TYPE OF DEVICE/MANUFACTURER

Honeywell/Envitec Oxygen Sensor

ACTION TAKEN

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

Example of how a piece of safety equipment can reduce the safety of the procedure.

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

144



29/7/26

Oxygen sensor

REPORT NO

143



1/6/26

Case report - runaway pressure module

REPORT NO

142



6/7/26

Isoflurane vaporiser

REPORT NO

141



26/6/26

EOPA cannula

REPORT NO

140



12/6/26

Isoflurane vaporiser

REPORT NO

139



20/5/26

Faulty pressure relief valve

REPORT NO

138



20/4/26

Oxygenator Changeout

REPORT NO

137



12/11/25

Disposables: vent valves

REPORT NO

136



28/1/26

Hardware: ACT machine

REPORT NO

135



3/2/26

Human Factors

REPORT NO

134



17/12/25

Disposables: Faulty vent valve

REPORT NO

133



7/7/25

Disposables: Oxygenator Failure

REPORT NO

132



11/6/25

Hardware: Maquet cardiosave hybrid

REPORT NO

131



23/10/24

Human Factors

REPORT NO

130



19/5/25

Hardware: Level Alarm

REPORT NO

129



3/5/25

Human Factors

REPORT NO

128



25/5/25

Single Station Selectatec Type Backbar for Vapouriser. 9000-001

REPORT NO

127



4/1/25

Eurosets Oxygenator leak

REPORT NO

126



1/3/25

Oxygenator Failure

REPORT NO

125



11/2/25

Hardware Error: Bubble Detector

REPORT NO

124



1/10/24

HCU/ Hardware incident/ Human Factors

REPORT NO

123



5/7/24

LivaNova S5 Roller Pump Fault

REPORT NO

122



5/4/24

Oxygenator Failure

REPORT NO

121



8/3/24

Disposables: Eurosets Adult ECMO Oxygenator

REPORT NO

120



1/5/24

Oxygenator Failure

REPORT NO

119



Hardware: HCU Contamination

REPORT NO

118



12/9/23

Human Factors: ECMO Mobilisation

REPORT NO

117



27/9/23

Disposables: Oxygenator failure

REPORT NO

116



14/9/23

Disposable Issue: Reservoir in CPB circuit

REPORT NO

115



13/9/23

Disposable Error/ Eurosets New Born ECMO oxygenator (EU5056) leak

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