Page 14 - ANZCP Gazette-August-Booklet

PIRS-II REPORT
Tim Wilcox CCP, LMANZCP, PIRS-II Editor
The PIRS-II pages on the ANZCP web is in-process of change. The old format needs refreshing and feedback from the recent PIRS-II survey (1) supports both direct email of reports and posting on the web. The UK website has a very user friendly format for their safety section and the ANZCP will adopt similar format concepts.
Reports remain spasmodic and the survey identified unit culture as an impediment to reporting amongst other well documented reporting barriers. We are bringing attention to what went well in near miss and no harm incidents that comprise the vast majority of submissions and provide the greatest ‘vaccine’ opportunity against serious adverse events. I have selected three recent submissions to illustrate examples of near miss type incidents resulting from recently introduced practice (Del Nido cardioplegia), well established risk (reversed vent), as well as a frequently reported cause of gas supply failure (displaced vaporiser).
The common thread to these (the latter two you might expect would be extremely unlikely given current HLM safety technology) is that they are all rule-based-errors – they are a failure to check equipment. While some of the incidents cited had checks included on the checklists (personal communication) these were ineffective, either by the checklist design, over familiarity with the checklist (an automaton reaction), or the action was not covered by an appropriate check. In all reports, the actions of the perfusionist or team averted serious harm and these interventions are what went well. In addition, a review of the reports resulted in alterations of the checklists to be more specific. Checklists are living documents and should be changed – not only as a result of new incidents that occur, but also in a refreshed format to minimise the automaton response. All three of these incidents have been previously reported to PIRS – the displaced vaporiser frequently. Both vent related air embolism and displaced vaporiser related gas failure reports have appeared in the recent literature (2–4) and it is reasonable to assume that near misses are still occurring in the current environment.
PIRS-II continues to provide useful lessons from reports of what went well and the applied solutions to unintended variations during CPB. Creating a culture that embraces reporting these unintended variations may save a colleague from falling into a similar trap. The del Nido report is a case in point. Various methods are in place to manage changing modes of cardioplegia and PIRS-II has seen several reports relating to associated problems. With the web revamp we will aim to group the reports and solutions to a more user friendly format to better provide a safety resource for perfusionists.
References
Willcox TW, Baker RA. Incident Reporting in Perfusion: Current Perceptions on PIRS-2. J Extra Corpor Technol. 2020;52(1):7-12.
Guy TS, Kelly MP, Cason B, Tseng E. Retrograde cerebral perfusion and delayed hyperbaric oxygen for massive air embolism during cardiac surgery. Interact Cardiovasc Thorac Surg. 2009;8(3):382-3.
Webb DP, Deegan RJ, Greelish JP, Byrne JG. Oxygenation failure during cardiopulmonary bypass prompts new safety algorithm and training initiative. J Extra Corpor Technol. 2007;39(3):188-91.
Gautam NK, Schmitz ML, Zabala LM, White MW, McKamie WA, Lutz A, et al. Anesthetic vaporizer mount malfunction resulting in oxygenation failure after initiating cardiopulmonary bypass: specific recommendations for the pre-bypass checklist. J Extra Corpor Technol. 2009;41(3):183-6.
Incident #1
Incident type
Good catch, no harm incident
Type of incident:
Management
Category
Circuit error
Description:
On a request to turn on a pump for a drop in sucker, the surgeon said it wasn’t working. The surgeon dipped it under water and found it was blowing. The sucker had been incorrectly loaded in the raceway in the reverse direction. There was no one-way non return valve in the line. The pump had been loaded by a supervisor standing at the rear of the HLM assisting a trainee. In hindsight this unusual approach disorientating the loading process. It was lucky that it was set up as a sucker and not a vent.
What went well
Having an observant surgeon.
The vent was used as a drop sucker rather than an aortic root vent or left heart vent pre aortic X clamp
Future preventive actions
Routinely performing a ‘dip test’ pre CPB of all sucker lines to check to avoid a potentially fatal outcome.
Including sucker dip test in the pre CPB checklist. One way valves in all tubing sets.
What could we do better
Incorporate the vent dip test into the pre CPB checklist
11 SEPTEMBER 2020 | www.anzcp.org