Page 13 - ANZCP GAZETTE DECEMBER 2023

PIRS REPORT
2023 Circuit disruption (Oxy temp port)
Permission to print: Category
Incident type Duration of incident: Description:
Yes
Circuit disruption Good Catch Near Miss minutes
Inspire 7F was used for a CABG procedure. While checking the CPB circuit, there was a few drops of priming on the floor beneath the oxygenator. System was double checked, the arterial sample port was mounted a bit skew, this was adjusted no leakage in the 5 minutes there after. On further inspection a drop of priming fluid was observed (confirmed on video) coming out of the inside of the oxygenator temperature probe port. The system was not sterile any more so we replaced the whole CPB circuit.
GOOD CATCH - what went well Check, check double check
What could we do better Preventive actions
Type of incident: Hospital incident filed: Ext Authority Advised Discussed with team: Knowledge issue Protocol issue
Skill issue
Team Issue
Patient outcome variance f
nothing
None, Company has been informed. Lab testing on the oxygenator will be done. Equipment
No
Yes
Yes
No
No
No
No
Nil
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