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

054



1/4/20

Leaking ALF

REPORT NO

053



1/2/20

Arterial Line Filter Leak

REPORT NO

052



1/3/19

Gas Line Filter Issue

REPORT NO

051



1/12/19

Dual Lumen Cannula Movement

REPORT NO

050



1/10/19

Venous Cannula Damaged

REPORT NO

049



1/12/19

Oxygenation Issue

REPORT NO

048



1/8/19

Roller Pump Failure

REPORT NO

047



1/12/19

Broken Cannula Dilator

REPORT NO

046



6/12/19

Gas Blender Error

REPORT NO

045



20/11/19

Tubing Detachments

REPORT NO

044



27/11/19

Interruption to IABP counterpulsation

REPORT NO

043



1/7/19

Getinge Mal-Position Of IABP Catheter

REPORT NO

042



1/2/19

Avalon Dual Lumen Cannula Crack

REPORT NO

041



1/2/19

Custodial Rubber Fragmentation In Spiked Bag

REPORT NO

040



1/10/18

Reservoir Clot

REPORT NO

039



1/10/18

Pall Clot In Cardioplegia Circuit

REPORT NO

038



1/10/18

Maquet HL20 Cardioplegia Pump Error

REPORT NO

037



1/10/17

Temed D200 Haemoconcentrator Clot

REPORT NO

036



1/10/17

Oxygenator issue

REPORT NO

035



1/10/17

Medtronic Fusion Oxygenator Blood To Gas Leak

REPORT NO

034



Possible Medtronic Fusion Oxygenator Failure

REPORT NO

033



Fannin Heparin Ampules Shattering

REPORT NO

032



Sucker Placed In Raceway In Wrong Direction

REPORT NO

031



High Transmembrane Pressure Gradients

REPORT NO

030



Faulty Connector On ECMO Soft Shell Reservoir Bag

REPORT NO

029



Sorin Inspire 8F Blood Leak From Temperature Port

REPORT NO

028



Sorin Inspire 8F Oxygenator Detached From Holding Arm

REPORT NO

027



Paragon Oxygenator Gas Inlet Leak

REPORT NO

026



Maquet IABP Console Failure

REPORT NO

025



Sorin EOS Gas To Blood Leak Whilst Priming

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