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
091
1/10/21
Oyxgenator Leak
REPORT NO
090
1/10/21
Breach of chemical cleaner
REPORT NO
089
1/9/21
Sechrist Gas Blender Sweep on ECMO
REPORT NO
088
1/9/21
Oxygenator High Pressure Events
REPORT NO
087
1/10/21
Leaking one way valve
REPORT NO
086
1/7/21
Electronic Gas Blender Fault
REPORT NO
085
1/2/21
Protamine Administration Issue
REPORT NO
084
1/6/21
Damaged roller pump lid
REPORT NO
083
1/6/21
IABP malfunction
REPORT NO
082
1/1/21
Accidental cardioplegia administration
REPORT NO
081
1/4/21
S5 Double Roller Pump incident
REPORT NO
080
1/5/21
Human factors issue
REPORT NO
079
1/6/21
Centrimag battery module failure
REPORT NO
078
1/6/21
Sampling manifold valve fault
REPORT NO
077
1/5/21
IABP transport issue
REPORT NO
076
1/4/21
Modified Ultrafiltration (MUF) Issue
REPORT NO
075
1/3/21
Electromagnetic interference with HLM
REPORT NO
074
1/2/21
HCU40 Failure
REPORT NO
073
1/2/21
HCU40 valve failures
REPORT NO
072
1/1/21
HCU40 failure
REPORT NO
071
1/1/21
LIVA NOVA STATEMENT ON CENTRIFUGAL HEAD
REPORT NO
070
1/1/21
Loose component on circuit
REPORT NO
069
1/12/20
Centrifugal Head noise
REPORT NO
068
1/11/20
Venous Reservoir disposable issue
REPORT NO
067
1/11/20
Failure of Heater Cooler due to leaking valves
REPORT NO
066
1/11/20
Failure of Valves on heater cooler unit
REPORT NO
065
1/9/20
Intra Aortic Balloon Pump (IABP) Failure
REPORT NO
064
1/9/20
Centrifugal head failure
REPORT NO
063
1/8/20
Centrifugal head issue 4
REPORT NO
062
1/8/20
Human Factors Issue
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