Accidents OR Mishaps In Perfusion

1
Accidents OR Mishaps In Perfusion

• S.Lenin
• Chief Clinical Cardiac Perfusionist
• Royal Hospital
• Sultanate of Oman

2
Accidents OR Mishaps In Perfusion

• Occassional
• Often
• TWO Categories
• Human error
• Equipment failures
• Terumo conf.Dubai June 2002

3
Accidents OR Mishaps In Perfusion

• Human error
• Inadequate knowledge
• Carelessness
• Overconfidence
• Poor investigations
• Poor communication
• Terumo conf.Dubai June 2002

4
Accidents OR Mishaps In Perfusion

• Human error
• Not only dedicated to ordinary situations
• Odd times
• Critical situations
• Terumo conf.Dubai June 2002

5
Accidents OR Mishaps In Perfusion

• Human error
• Poor medical ethics
• Interdepartmental politics Or Ego
• Untidiness and disorganised setups
• Terumo conf.Dubai June 2002

6
Accidents OR Mishaps In Perfusion

• Equipment failures
• Very rare
• Unpredictable
• Unpreventable
• Electric
• Electronic
• Mechanical
• Terumo conf.Dubai June 2002

7
Accidents OR Mishaps In Perfusion

• Equipment failures
• Over work OR Fatigue
• Improper maintenance
• Wrong selection
• Poor manufacturing standards
• Can be traumatic or fatal
• Terumo conf.Dubai June 2002

8
Accidents OR Mishaps In Perfusion

• Equipment failures
• Attention, resolve at the earliest
• Failure attracts the attention of many
• Too many opinions
• Confusion - Perfusionist - Diversion
• Terumo conf.Dubai June 2002

9
Accidents OR Mishaps In Perfusion

• Equipment failures
• Loss of time leads to fatal results
• Leads to Mass Media Publication
• Sue the personnel
• Terumo conf.Dubai June 2002

10
Accidents OR Mishaps In Perfusion

• Equipment failures
• Successful management
• New protocols
• Inventions
• Applications
• Terumo conf.Dubai June 2002

11
Accidents OR Mishaps In Perfusion

• 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.
• Terumo conf.Dubai June 2002

12
Accidents OR Mishaps In Perfusion

• TO Err is human
• Acceptance gains knowledge
• Denial fools self
• Knowledge gets ignored
• Terumo conf.Dubai June 2002

13
Accidents OR Mishaps In Perfusion

• How to avoid accidents?
• Sound Knowledge
• Regular updates
• Regular Maintenance of equipments.
• Build up of trust and team spirit
• Terumo conf.Dubai June 2002

14
Accidents OR Mishaps In Perfusion

• 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
• Terumo conf.Dubai June 2002

15
Accidents OR Mishaps In Perfusion

• Follow the standards of perfusion
• Good data management
• Check list and double check
• Reconfirmation of settings
• Vigilant always
• Never be overconfident
• Terumo conf.Dubai June 2002

16
Accidents OR Mishaps In Perfusion

• 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

17
Accidents OR Mishaps In Perfusion

• Saftey gadgets gives relaxation to the operating
  perfusionist
• Keep the safe timing limits
• Develop good organising skills
• Methodic approach
• Terumo conf.Dubai June 2002

18
Accidents OR Mishaps In Perfusion

• Develop scanning pattern on vital parameters
• Enlighten the team - Plan
• Quick implementation
• Terumo conf.Dubai June 2002

19
Accidents OR Mishaps In Perfusion

• 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
• Terumo conf.Dubai June 2002

20
Accidents OR Mishaps In Perfusion

• Always read the drug label
• Never follow the color or shape of the vial or
  container
• May lead to increase in Morbidity and mortality
• Terumo conf.Dubai June 2002

21
Accidents OR Mishaps In Perfusion

• Overcoming Accidents
• Learning
• An ongoing process
• Universal
• No age limit
• Do not deny the opportunity
• Dedicate your time and age for achievements.
• Terumo conf.Dubai June 2002

22
Accidents OR Mishaps In Perfusion

• Ultimate Goal
• Save the life inspite of all the odd situations
• Prevent the re-occurrence
• Draft protocols and applications
• Be committed to the profession
• Terumo conf.Dubai June 2002

23
Accidents OR Mishaps In Perfusion

• Ultimate Goal
• Do not work for rewards alone
• Earn the confidence of the team
• Knowledge, hard work and efficiency
• Earns a better living
• Terumo conf.Dubai June 2002

24
Accidents OR Mishaps In Perfusion

• Ultimate Goal
• Sincereity, punctuality, honesty, vigilance,
  dedication, thorough knowledge and good
  communication
• Earns a good professional
• Terumo conf.Dubai June 2002

25
Accidents OR Mishaps In Perfusion

• Medicine without team work
• is a SIN.
• Discuss the problems in common
• Share your experiences with the team
• Terumo conf.Dubai June 2002

26
Accidents OR Mishaps In Perfusion

• CONSTANT UPDATE
• Text books
• Media
• CME
• Conferences National, International
• Medical exhibitions
• Help to develop the management skills of the
  perfusionist
• Terumo conf.Dubai June 2002

27
Accidents OR Mishaps In Perfusion

• Worldwide experience shows
• Human errors 90
• Equipmental errors
• Terumo conf.Dubai June 2002

28
Accidents OR Mishaps In Perfusion
Thank you