PERFUSION REPORTS

REPORT
147
DATE
9/9/2026
TITLE
Isoflurane vaporiser
DETAILS OF INCIDENT

Intermittent flow through vaporiser that rectified when the vaporiser and backbar were removed from the circuit.

DETAILS OF INJURY TO PATIENT
TYPE OF DEVICE/MANUFACTURER

AE Services, Isotec MK3. SN 5012401

ACTION TAKEN

Removed and sent to clinical engineering. Replaced with another vaporiser and backbar.

‍

RESPONSE FROM MANUFACTURER
ADDTIONAL INFORMATION
SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION
 REPORTS

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REPORT NO
151
15/9/26
Gas line disconnection
REPORT NO
150
21/10/26
Governance issue of undocumented IABP therapy
REPORT NO
149
15/9/26
Oxygen sensor gas leak
REPORT NO
148
14/9/26
Consumables - cracked cardioplegia table line
REPORT NO
147
9/9/26
Isoflurane vaporiser
REPORT NO
146
19/5/26
Oxygen sensor gas leak
REPORT NO
145
6/8/26
Disposables: Faulty cardioplegia cannula
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
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