DATE
03-2012
FSN
015
TITLE
Sucker Placed In Raceway In Wrong Direction
PROBLEM

During a routine valve procedure the operating surgeon placed a transeptal vent into the Left Ventricle (LV). When the vent pump was turned on it was noticed that the LV did not empty and air bubbles were seen in the left coronary arterial tree and a significant amount of air appeared to be in the LV on Transoesophageal Echo.

The problem was that the sucker used to vent the heart was not sucking. Another sucker was used and this rectified the problem. The LV emptied and the procedure continued. The patient suffered some neurological deficit that slowly resolved that was put down to this air embolus. It was felt that the sucker failure was due to the tubing in the raceway of that sucker being placed in the wrong direction.

ACTION TAKEN

There are a number of issues here, direction of pump rotation, orientation of tubing in the pump raceway and adequate testing of suckers. The most effective method of preventing this error is the wet table test with the scrub nurse. We urge all units to adopt this final check for all suckers.

This error has appeared on this site recently and demonstrates again the value and importance of checking the suckers and vents actually suck and this can best be checked by dipping the tubing into a jug of fluid on the table. The Safety Committee would again like to encourage the appropriate use of checklists at all stages of the operation to ensure we deliver the safest possible bypass to our patients.

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