PERFUSION REPORTS

REPORT
146
DATE
19/5/2026
TITLE
Oxygen sensor gas leak
DETAILS OF INCIDENT

Gas blender was set to 4lpm flow and on checking the gas line it was felt to be lower. Gas flow was checked with a flow meter which only read 2lpm. The gas leak was found to be at the oxygen sensor.

DETAILS OF INJURY TO PATIENT
TYPE OF DEVICE/MANUFACTURER

Teledyne oxygen analyser. Asset number 5003572

ACTION TAKEN

Source of gas leak found to be at the oxygen sensor. Changed out for a new sensor and the issue resolved. Faulty sensor sent to clinical engineering.

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RESPONSE FROM MANUFACTURER
ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION
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15/9/26
Gas line disconnection
REPORT NO
150
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REPORT NO
149
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REPORT NO
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REPORT NO
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REPORT NO
146
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REPORT NO
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6/8/26
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REPORT NO
144
29/7/26
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REPORT NO
143
1/6/26
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REPORT NO
142
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141
26/6/26
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REPORT NO
140
12/6/26
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REPORT NO
139
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REPORT NO
138
20/4/26
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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
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REPORT NO
125
11/2/25
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REPORT NO
124
1/10/24
HCU/ Hardware incident/ Human Factors
REPORT NO
123
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LivaNova S5 Roller Pump Fault
REPORT NO
122
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Oxygenator Failure
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