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Australasian perfusion incident survey

O F Jenkins1, R Morris, J M Simpson

  • 1Perfusion Department, St George Hospital, Sydney, Australia.

Perfusion
|September 23, 1997
PubMed
Summary

A survey of cardiac surgery perfusionists in Australia and New Zealand found a high safety level. Improved incident reporting, particularly for perfusion accidents, can further enhance patient safety during cardiopulmonary bypass.

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Area of Science:

  • Cardiovascular Surgery
  • Perfusion Technology
  • Patient Safety

Background:

  • Perfusion accidents and incidents can compromise patient safety during cardiac surgery.
  • Understanding the frequency and types of incidents is crucial for improving safety protocols.

Purpose of the Study:

  • To retrospectively survey perfusionists in Australia and New Zealand regarding perfusion accidents, incidents, and safety procedures.
  • To assess the incidence of serious injuries and deaths related to cardiopulmonary bypass.
  • To evaluate the use of safety equipment and procedures in perfusion practice.

Main Methods:

  • Anonymous postal survey of eligible perfusionists in all identifiable cardiac surgery units in Australia and New Zealand.
  • Data collected over an 18-month period (January 1994 to July 1995).
  • Response rate of 69% from perfusionists representing 39-42 operating units.

Main Results:

  • Most frequent incidents included heater/cooler failure (43%), urgent return to bypass (38%), and hospital power failure (31%).
  • The overall rate of serious injury or death was 1 in 1300 cases; the perfusion-related injury rate was 1 in 2500 perfusions.
  • Widespread use of safety equipment: all used low-level alarms, 74% used bubble detectors, 82% used arterial line filters, and 80% used checklists.

Conclusions:

  • The level of safety in perfusion in Australasia is high, with a lower injury rate than reported elsewhere.
  • Increased incident reporting may reflect a growing accountability among perfusionists.
  • Further improvements in practices can be achieved through enhanced incident reporting systems.

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