DATE
07-2011
FSN
011
TITLE
Aorta Remained Clamped Post CPB
PROBLEM

At the end of a routine cardiac surgical procedure, Cardiopulmonary Bypass (CPB) was terminated, however, it was not noticed at this time there was still a clamp fully occluding the aorta. Once this was realised and removed and despite the best efforts of the team the patient sadly passed away.

ACTION TAKEN

The patients' safety is paramount and if there is any doubt about patient blood pressure monitoring the safest course of action is to return to CPB. No measured parameters should be disregarded without concrete evidence to the contrary or without consulting the multi-disciplinary team. At key events during any procedure such as application or removal of clamps there should be a check and cross-check communication verification between team members. Standard Operating Procedures for the various phases of CPB should be implemented and if necessary specific checklists should be used.

DOWNLOADS
USEFUL LINKS

FIELD SAFETY NOTICES (FSN)

London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Select and scroll to view FSN Details
REPORT NO
021
DATE
03-2017
Infections Associated With HCUs In CPB & ECMO
REPORT NO
020
DATE
09-2015
Potential Mycobacterial Contamination Of HCUs
REPORT NO
019
DATE
02-2014
SWISSMEDIC: Water-Borne Infection In Implant Patients
REPORT NO
018
DATE
01-2014
Maquet Cardioplegia Temperature Reading Inaccuracies
REPORT NO
017
DATE
02-2013
Hypercoagulable Disorder May Have Led To Oxygenator Failure
REPORT NO
016
DATE
01-2013
LV Vent Placed In Raceway In Wrong Direction
REPORT NO
015
DATE
03-2012
Sucker Placed In Raceway In Wrong Direction
REPORT NO
014
DATE
02-2012
Similarity In Heparin And St Thomas Cardioplegia Ampules
REPORT NO
013
DATE
01-2012
Maquet Adhesive Failure On Oxygenator Blood Outlet Connector
REPORT NO
012
DATE
08-2011
Sorin Heat Exchanger Blood Water Leak
REPORT NO
011
DATE
07-2011
Aorta Remained Clamped Post CPB
REPORT NO
010
DATE
06-2011
Maquet Transient Increase In Pump Speeds
BACK TO SAFETY ARCHIVE