Blood line pull-off or blow-off narrative.
Anyone interested in perfusion safety should visit the Australian & New Zealand College of Perfusionists website (http://www.anzcp.org/index.htm) and read the Perfusion Incident Report System (PIRS) entries. The objectives of the PIRS are to:
1) increase confidential incident and accident reporting in the perfusion community.
2) provide feedback on incidents.
3) provide the means for proactive and reactive safety review.
4) create a safety culture.
They have been collecting data since 2005 and have complete reports dating back to 2012. I currently organize CPB FMEAs into only 12 categories, but the PIRS uses 27 categories for perfusion incidents and accidents. If you think that some of the hypothetical failures used in my FMEAs are far-fetched, just spend time reading the PIRS reports that describe the incredible real-life failures that have actually occurred. Many of them could have been prevented by better preemptive management. Some of the most common incidents include drug and medication incidents and air in the circuit. But by far the most commonly reported incidents involve circuit disruptions.
Reading the PIRS entries, the question arises; what is the difference between a ‘failure’ and an ‘accident’? Some might say that a failure is avoidable and an accident is not; some accidents being beyond a perfusionist’s control. I dispute that. The whole reason behind an FMEA is to envision any accident that could conceivably occur and plan preemptive management techniques to prevent the occurrence or use management techniques to mitigate the problem if it does occur.
One of the PIRS circuit disruption reports states “…arterial pump boot connection started to leak on the positive pressure side connector. Touched it to see how much blood was coming out and it hosed a fine jet out. Decided not to touch it again…..watched it for a few minutes, gauging the leak. Was nervous about using the tie gun on the pulsing shaking connector, thought it might fail dramatically. Turned the flow right down briefly and put a further tie on the connector next to the one already on. Increased flows, no further leaking.” This incident just missed causing serious patient harm. Under the PIRS preventative plan the author recommends using glue and additional ties at manufacture. Ties, yes, but I don’t agree with the glue. Was this incident a failure or an accident? Was it avoidable or inevitable; i.e., beyond the perfusionist’s control? You decide.
In deference to this particular PIRS I decided to write this FMEA dealing with a simple pull-off or blow-off between a blood line and connector or blood port. The most fundamental task of a perfusionist is to assemble, inspect and test an extracorporeal circuit before it is used on a patient. Despite this, there are a lot of failures like the one described above. Please give me your take on how to make this FMEA better and more relevant.
Gary Grist RN CCP Emeritus