Description of Event or Problem · 1
WE HAVE HAD SEVERAL INCIDENTS OF THE BRAT 2 UNITS FAILING TO PROPERLY WASH HEPARIN FROM BLOOD SCAVENGED OFF THE SURGICAL SITE. THERE WERE QUESTIONS AS TO WHETHER THIS WAS CAUSED BY A DEVICE FAILURE OR DUE TO OTHER CIRCUMSTANCES. WE FOUND THAT THIS WAS CAUSED BY THE USER FAILING TO OPEN THE CLAMP BELOW THE WASH BAG, THUS CUTTING OFF A WASH FLUID SUPPLY TO THE BRAT 2. THIS MORNING TESTS RESULTS FOUND THAT THE BRAT 2 DOES NOT HAVE A GOOD MECHANISM IN PLACE FOR DETECTING A LACK OF WASH FLUID SUPPLY. THERE IS AN AIR DETECTOR THAT IS IN LINE WITH INCOMING WASH FLUID WHICH DETECTS WHETHER OR NOT THE TUBE IS EMPTY OR NOT, OR FILLED WITH BUBBLES. HOWEVER, THIS LINE IS ALSO THE LINE USED TO FILL THE BOWL WITH BLOOD PRIOR TO THE WASH CYCLE. THEREFORE, IF THE WASH FLUID SUPPLY IS CLAMPED, AND THERE IS STILL RESIDUAL BLOOD IN THE FILL LINE AT THE POINT OF THE AIR DETECTOR -WHICH WOULD BE LIKELY GIVEN NO WASH HAD YET OCCURRED-, THE AIR DETECTOR STILL SEES FLUID -ALTHOUGH IT IS BLOOD, NOT WAS FLUID- AND DOESN'T REALIZE THERE IS A PROBLEM. THE BLOOD IN THE LINE WOULD TRICK THE UNIT INTO THINKING THAT THERE WAS WASH FLUID FLOWING DURING THE WASH CYCLE, EVEN THOUGH IT WAS CLAMPED OFF AT THE BAG. THIS WOULD PREVENT THE HEPARIN FROM BEING WASHED OUT OF THE SPUN BLOOD. COBE TECHNICAL SERVICE REPRESENTATIVE WAS CONTACTED AND HE AGREED THAT THIS IS THE CASE. HE SAID THAT JUST AS BUBBLES AT THE AIR DETECTOR CAN TRICK THE UNIT INTO THINKING THAT THE UNIT IS EMPTY, RESIDUAL FLUID IN THE LINE AT THE POINT OF THE AIR DETECTOR CAN CAUSE IT TO THINK THERE IS FLUID FLOWING. THIS IS A CONDITION THAT ALL BRAT 2 USERS SHOULD BE AWARE OF.