Any perfusionist can operate a heart/lung system on their own, but what happens if the arterial pump fails? (S)he can hand crank the machine, but who is going to retrieve and swap out an alternate pump to restore the function of the failed one?
That’s the question posed by Gary Grist, RN, CCP. In a recent safety presentation created by Grist for the American Society of Extracorporeal Technology, he theorizes the perfusion profession has become too overconfident.
“In an emergency like a failed roller pump, the sole perfusionist cannot hand crank the pump and at the same time fetch and install a replacement without placing the patient at great risk,” he notes. “The Titanic carried the number of lifeboats required by regulations and no more simply because its builders did not envision [any way] that the vessel could sink.”
Grist uses information from the U.K.’s Gritten Report, which outlines the incidents that led to the death of a pediatric patient undergoing complex cardiac surgery to make his point. Mark Gritten found the infant died as a result of a CaCl2 overdose from the perfusionist, and that the perfusion profession suffered from a lack of regulation, protocols and guidance.
What is Perfusion Safety?
Grist defines perfusion safety as “the avoidance of unnecessary incidents that result in adverse patient outcomes.” These incidents fall into four main categories:
- Defective or malfunctioning equipment or supplies
- A failure of communication among healthcare professionals
- Human error
- Failure to anticipate adverse events
How to Achieve Perfusion Safety
How does a profession with little regulation and protocols improve safety? Grist lays out seven steps perfusionists and healthcare professionals should take:
- Provide policies, procedures and processes that provide authorization and specific instructions for performing tasks in the safest and most effective manner.
- Have safety devices like hand cranks, arterial line filters, bloodline pressure pump shut-off, independent flow meters and more on hand to prevent injury or accident.
- Use checklists to ensure consistency and completeness of tasks. For example, a checklist could be used to ensure the pump and all of its parts are available and operating properly before a procedure begins.
- Keep documents on all personnel competency training.
- Troubleshoot problems as they occur.
- Use Root Cause Analysis (RCA) to drill down to the underlying cause(s) of a serious failure, and propose actions or conditions that could have prevented that failure.
- Use Failure Mode Effects Analysis (FMEA) to examine how a system can fail before the failure happens. Identify potential problems with this method by itemizing possible failures, describing the consequences of the failure, describing the action that’s causing the failure, listing the actions that can mitigate or prevent the failure and ranking how dangerous each failure is.
For more information on how to mitigate risk, what to do if you don’t have adequate safety equipment or help, take a look at Grist’s entire presentation.
