title: A retrospective study on perfusion incidents and safety devices.
abstract: Despite the acceptance of extracorporeal circulation as an effective modality to facilitate cardiac surgery, patient outcomes can be negatively influenced by the occurrence of perfusion incidents. A perfusion survey was conducted to identify safety techniques and incidents related to cardiopulmonary bypass (CPB). An 80-question survey was mailed to chief perfusionists of all 1030 USA cardiac surgical centers using CPB. The survey was designed to examine practices and incidents that occurred during a 2-year period (July 1996 to July 1998). Five-hundred-and-fifty-two (54% response rate) surveys were returned, which accounted for 797 hospitals (79% of all cardiac centers) and 653,621 surgical procedures. Of the 27 identified CPB safety devices, the highest utilization was arterial line filters (98.5%) and the lowest arterial line bubble traps (3.4%). Of the reported cases, a CPB incident occurred once every 138 cases. The most common occurring incidents were protamine reactions (1:783), coagulation problems (1:771), and heater/cooler failures 11:1809). The rate of occurrence of an incident resulting in a serious injury or death was one for every 1453 procedures. Although techniques and safety devices create a relatively secure environment for CPB, lower incident rates may be achieved with further improvements in coagulation monitoring and incident reporting.
authors.affiliation: Division of Clinical Perfusion Education, University of Nebraska Medical Center, Omaha 68198-5155, USA.
authors.forename: B L
authors.initials: BL
authors.lastname: Mejak
authors.forename: A
authors.initials: A
authors.lastname: Stammers
authors.forename: E
authors.initials: E
authors.lastname: Rauch
authors.forename: S
authors.initials: S
authors.lastname: Vang
authors.forename: T
authors.initials: T
authors.lastname: Viessman
mesh_terms: D004869:Equipment Safety; D004864:Equipment and Supplies / Q000592:standards; D005112:Extracorporeal Circulation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D006801:Humans; D012189:Retrospective Studies; D011795:Surveys and Questionnaires