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Accidents OR Mishaps In Perfusion. S.Lenin Chief Clinical Cardiac Perfusionist Royal Hospital Sultanate of Oman. Accidents OR Mishaps In Perfusion. Occassional Often TWO Categories: Human error Equipment failures Terumo conf.Dubai June 2002. Accidents OR Mishaps In Perfusion.
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Accidents OR Mishaps In Perfusion S.Lenin Chief Clinical Cardiac Perfusionist Royal Hospital Sultanate of Oman
Accidents OR Mishaps In Perfusion • Occassional • Often • TWO Categories: • Human error • Equipment failures Terumo conf.Dubai June 2002
Accidents OR Mishaps In Perfusion • Human error • Inadequate knowledge • Carelessness • Overconfidence • Poor investigations • Poor communication Terumo conf.Dubai June 2002
Accidents OR Mishaps In Perfusion • Human error • Not only dedicated to ordinary situations • Odd times • Critical situations Terumo conf.Dubai June 2002
Accidents OR Mishaps In Perfusion • Human error • Poor medical ethics • Interdepartmental politics Or Ego • Untidiness and disorganised setups Terumo conf.Dubai June 2002
Accidents OR Mishaps In Perfusion • Equipment failures: • Very rare • Unpredictable • Unpreventable • Electric • Electronic • Mechanical Terumo conf.Dubai June 2002
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
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
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
Accidents OR Mishaps In Perfusion • Equipment failures: • Successful management: • New protocols • Inventions • Applications • Terumo conf.Dubai June 2002
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
Accidents OR Mishaps In Perfusion • TO Err is human • Acceptance gains knowledge • Denial fools self • Knowledge gets ignored • Terumo conf.Dubai June 2002
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
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
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
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
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
Accidents OR Mishaps In Perfusion • Develop scanning pattern on vital parameters • Enlighten the team - Plan • Quick implementation • Terumo conf.Dubai June 2002
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
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
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
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
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
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
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
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
Accidents OR Mishaps In Perfusion • Worldwide experience shows : • Human errors > 90% • Equipmental errors <10% • Terumo conf.Dubai June 2002
Accidents OR Mishaps In Perfusion • Terumo conf.Dubai June 2002 Thank you