accidents or mishaps in perfusion s.lenin chief clinical cardiac perfusionist royal hospital...

Accidents OR Mishaps In Perfusion

S.LeninChief Clinical Cardiac Perfusionist

Royal HospitalSultanate of Oman


• Occassional

• Often

• TWO Categories:

• Human error

• Equipment failuresTerumo conf.Dubai June 2002


• Human error

• Inadequate knowledge

• Carelessness

• Overconfidence

• Poor investigations

• Poor communicationTerumo conf.Dubai June 2002


• Human error

• Not only dedicated to ordinary situations

• Odd times

• Critical situations

Terumo conf.Dubai June 2002


• Human error

• Poor medical ethics

• Interdepartmental politics Or Ego

• Untidiness and disorganised setups



• Equipment failures:

• Very rare

• Unpredictable

• Unpreventable

• Electric

• Electronic

• MechanicalTerumo conf.Dubai June 2002



• Over work OR Fatigue

• Improper maintenance

• Wrong selection

• Poor manufacturing standards

• Can be traumatic or fatal




• Attention, resolve at the earliest

• Failure attracts the attention of many

• Too many opinions

• Confusion - Perfusionist - Diversion

• Terumo conf.Dubai June 2002



• Loss of time leads to fatal results

• Leads to Mass Media Publication

• Sue the personnel




• Successful management:

• New protocols

• Inventions

• Applications



• Accidents Only to Medical Field?• Common to any given speciality.

• More common in teaching institutions

• Interns and Students

• Does not spare even the most experienced and in the hands of observers.



•TO Err is human•Acceptance gains knowledge•Denial fools self•Knowledge gets ignored



• How to avoid accidents?

•Sound Knowledge•Regular updates•Regular Maintenance of equipments.

•Build up of trust and team spirit



•Trust is a natural and basic instinct

•We have to develop the trust within team members

• It is a bond which reassures and comforts.

•Strengthens the relationship•Changes the quality of the person



•Follow the standards of perfusion

•Good data management•Check list and double check•Reconfirmation of settings•Vigilant always•Never be overconfident



•Good communication•Sharpness in sight, hearing and reasoning

•Engage all the saftey gadgets on the HLM

•Widens the saftey window•Machines have alarm, alert and auto shut off Terumo conf.Dubai June 2002


•Saftey gadgets gives relaxation to the operating perfusionist

•Keep the safe timing limits•Develop good organising skills•Methodic approach



•Develop scanning pattern on vital parameters

•Enlighten the team - Plan•Quick implementation



•Standards to follow:•Document all the vital parameters, history of the Patient

•Appropriate the equipment selection and the disposables as per the patients need

•Never go with blind approaches



•Always read the drug label •Never follow the color or shape of the vial or container

•May lead to increase in Morbidity and mortality



•Overcoming Accidents:•Learning–An ongoing process–Universal–No age limit–Do not deny the opportunity

•Dedicate your time and age for achievements.



•Ultimate Goal:•Save the life inspite of all the odd situations

•Prevent the re-occurrence•Draft protocols and applications

•Be committed to the profession



• Ultimate Goal:

•Do not work for rewards alone•Earn the confidence of the team•Knowledge, hard work and efficiency

•Earns a better living



• Ultimate Goal:

•Sincereity, punctuality, honesty, vigilance, dedication, thorough knowledge and good communication

Earns a good professional



•Medicine without team work is a SIN. •Discuss the problems in common •Share your experiences with the team



•CONSTANT UPDATE •Text books•Media•CME•Conferences National,

International•Medical exhibitions•Help to develop the management

skills of the perfusionist



• Worldwide experience shows :

• Human errors > 90%• Equipmental errors <10%


accidents or mishaps in perfusion s.lenin chief clinical cardiac perfusionist royal hospital...

Documents

perfusion accidents

fatal terumo conf

ignored terumo conf

personnel terumo conf

diversion terumo conf

person terumo conf

overconfident terumo

perfusion trust