1. MATCVS 2018 19TH ANNUAL SCIENTIFIC MEETING
PRE CONGRESS MEETING PERFUSIONIST WORKSHOP
09th AUGUST 2018
SHERATON PETALING JAYA
46200 SELANGOR, MALAYSIA

3. Topic..
THE SELECTED CASE STUDIES OF INCIDENCE AND ADVERSE EVENTS RELATED TO EXTRACORPOREAL CIRCULATION

4. Perfusion Safety
What AmSECT say??

5. Malfunctioning or defective equipment and supplies
Failure to anticipate
adverse events
The avoidance of unnecessary incidents that result in adverse patient outcomes
Human error or incorrect execution of procedures
Communication failure between healthcare professionals

6. Incident and Adverse Event Well- Known Surveys
The first survey entitled “Australasian perfusion incident survey” by Jenkins, Morris and Simpson, was published in Perfusion 1997;12:
The second survey entitled “An update on perfusion safety: does the type of perfusion practice affect the rate of incidents related to cardiopulmonary bypass”
by Stammers & Mejak, was published in
Perfusion 2001;16:

7. 80% 40% Jenkins, Morris and Simpson, 1997 (0.04%)
Stammers and Mejak, 2001 (0.7%)

8. After 20 years….
Is CPB today safer with a lower risk or do the same incidents occur? If it still happen.. is the frequency different? Are there newer risks associated with new techniques, equipment and procedures?

9. After 20 years….
But… We can agree that the devices used for CPB today are better and more reliable than in 1990s

11. Rate

12. Things To Ponder..
Australian Perfusion Survey 0.04% (1997) US Perfusion Survey 0.7% (2001) Japan Perfusion Survey 1.8% (2013)

13. Again After 20 years….
Is CPB today safer with a lower risk or do the same incidents occur? If it still happen.. is the frequency different? Are there newer risks associated with new techniques, equipment and procedures?

14. Again After 20 years….
We still can agree that the devices used for CPB today are better and more reliable than in 1990s But…

15. After 20 years….
Even with refinements in Perfusion equipment's and techniques as well as increase use of computer assistance and automation, the risk is still unavoidable…

16. The key ingredient of Perfusion Safety will remain the knowledge and expertise of the Perfusionist

17. CASE 1
Reference :

19. How to justify/estimates HLM life expectancy??
Wear and Tear issues
Technical Support
Performance Test
Depreciation
Spare parts
Obsolete

24. CASE 2

25. CASE 2

26. CASE 2

28. Where is our servo-regulator located at HLM
Where is our servo-regulator located at HLM?? Is it safe/risk if any unexpected splash or leaking occur at CPB circuit?? Where is the best place to locate it??

29. RISK ASSESSMENT What is current status on the
towards Perfusion Practice??

30. A risk assessment is the combination effort of:
Identifying and analysing potential events that may negatively impact individuals, assets, and/or the environment (risk analysis)
Making judgements on the ‘tolerability of the risk’ after establishing a risk analysis while considering influencing factors (risk evaluation)

31. Simplifying Risk Assessment…
Art of analyses :
What can go wrong
How likely it is to happen
What the potential consequences are How tolerable the identified risk is

32. CASE 3
The Gritten Report 2007

33. CASE 3

42. Take home notes..
The risk assessment is important tools in guiding Perfusionist to anticipate, predict and forecast any significant or non significant risk/hazard Establishment of National Perfusion Practice Standards– collaborations between all parties including MAPS Updating current perfusion protocol Collaboration in training and development

43. Thank you..