ECMO FMEA #13 Failure to prevent ECMO circuit or system damage during intra hospital transport.
This ECMO FMEA was inspired by a recent PIRS II report (#111 of 2020 <https://anzcp.org/wp-content/uploads/reports/2020/PIRS-2020-ECMO.pdf>) of an ECMO circuit disruption during preparation for an intra hospital transport. A motorized bed collided with an ECMO system rupturing a temperature probe on… Read More
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… Read More
On Becoming an Unassuming Perfusionist By Gary Grist RN CCP Emeritus
Definition: Assuming – supposing to be the case without supporting proof. Definition: Unassuming – not pretentious or arrogant; modest. (In my context, unassuming means not to take anything for granted, but to question authority and speak up when things don’t… Read More
Safety Tips: Part Two – Redundancy By Gary Grist RN CCP Emeritus
John Nance And Redundant Systems Many years ago, I heard a lecture by an aviation safety expert and accident analyst named John Nance. He said that the lives of the occupants of an airliner should not be dependent on a… Read More
SAFETY TIPS: Anticipating Adverse Events by Gary Grist RN CCP Emeritus
Perfusion safety is the avoidance of unnecessary incidents that result in adverse patient outcomes. These incidents usually involve 1) malfunctioning or defective equipment or disposables, 2) communication failure between healthcare professionals, 3) human error or incorrect execution of procedures and… Read More