Perfusion CQI: Failed Heat Seal on Recirc Line Connection
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Event Description:
Began setting up for a morning case, this was a dry setup from the day before- noticed that the recirc line was separated at the junction point immediately distal to where a one-way valve was usually in place. Looked closely- and the to ends were too loose to fit together. I believe it is usually a heat sealed connection. Cut the connections sites away- and reconnected recirc line with a 1/4″ x 1/4″ straight connector.
How Was The Problem Identified?
- Lines were separated prior to beginning a morning setup.
What Steps Were Taken ?
- Connectors cut off
- Reconnected recirc line with a 1/4″ x 1/4″ straight connector.
- Issue Resolved
What Clues Were Missed?
- None: Everything was double and triple checked.
Discussion:
- I had noticed with this particular ECC circuit- that the 1-way valve connection always seemed at an odd angle. I never really double checked to insure tightness of the fitting and integrity of the connection.
- This definitely a manufacturing issue/failure- and has occurred twice now (per discussion after the fact with a colleague who has seen it before on the same type of circuit.
Outcome:
- No issues.
Comments:
- None
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