Issue |
J Extra Corpor Technol
Volume 20, 1988
Proceedings of AmSECT’s 26th International Conference
|
|
---|---|---|
Page(s) | 103 - 105 | |
DOI | https://doi.org/10.1051/ject/198820S103 | |
Published online | 25 August 2023 |
Original Article
Perfusion Error Cause Removal: The Perfusion Case Conference
1
Department of Surgery, School of Medicine, University of Colorado Health Sciences Center, Denver, Colorado
2
PSICOR Inc., San Diego, California
* Direct communications to: Charles M. Tyndal Jr., 16818 Via del Campo Court, San Diego, CA 92127.
Prevention of accidents is one of the fundamental elements of perfusion quality. Unfortunately, errors and accidents frequently occur during cardiopulmonary bypass. A recent retrospective survey of perfusionists identified some common accidents. We have previously reported a method of developing protocols to prevent and treat the ten most common perfusion related problems.
Until we reach the day when perfusion accidents no longer occur, we need to be able to systematically evaluate failures and prevent their recurrence.
We have developed a non-judgmental forum to discuss, analyze, and prevent variances or unusual circumstances that occur during cardiopulmonary bypass. We hold a monthly case conference where we discuss all cases from which we can learn something–interesting cases and cases during which there was a departure from protocol.
The purpose of this paper is to discuss the development of a case conference and to outline the format and benefits of such an Error Cause Removal program.
© 1988 AMSECT
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