April 2026 Update :
PIRS2 is looking to share selected deidentified feedback that we receive linked to submitted reports where it offers practical insights for risk prevention and system improvement. This material is shared in a constructive, non-judgemental spirit to support learning across the perfusion community.
By way of example, a regular perfusion educator correspondent to PIRS made this pertinent observation on response to a recent report we thought worth sharing:
“One technique I used for students was to not only use a pre-bypass check list, which may or may not list the various clamps, and other items, but also do a visual check to:
“Follow the fluid flow. The fluid comes from (?) and goes to (?).”
There were numerous times in my career when the staff “and/or” student completed the pre-bypass check list and I would ask: “Are you sure everything is acceptable?”
Then I would have them follow the fluid and/or air flow to see if any item/step were missing.
Surprising, in some cases they still missed the error, and could be considered a lack of attention to details…….. NOTE: Even a closed clip on a cardioplegia line can leak fluid because the tubing was twisted outside the clamp area.)”
