Harm range: Minimal temporary harm to death.
Extracorporeal membrane oxygenation (ECMO) utilizes an external machine to take over the function of the heart and lungs, allowing the organs to rest and potentially recover. Though ECMO is a life-saving intervention for critically ill children, environmental factors can affect human behavior, resulting in errors such as technical missteps, inadequate monitoring, or circuit-related maintenance complications (Sakurai & Singhal). While the inherent risks of ECMO — such as seizures, stroke, and infection — are well recognized, the vulnerabilities stemming from human behaviors are sometimes overlooked and demand immediate attention.
Causes
Contributing factors may include:
- Arterial/venous site access difficulty due to body size
- Failure to recognize procedural missteps during emergent situations
- Mispositioned ECMO cannula tip due to congenital changes in heart anatomy
- Loose connection points within the ECMO circuit
- Accidental or intentional manipulation of the cannula
- Inadequate site checks to assess cannula placement depth and integrity
Harm
Complications during ECMO care can result in substantial blood loss, leading to death. The most significant harm events occurred during the maintenance phase when fewer ECMO staff were present to respond to the complication.
Recommendations
- Ensure competent individuals who perform cannulation are present or on call with appropriate surgical backup plans.
- Require interprofessional simulation and drill scenarios that include pump failure, emergency circuit clamping measures, and inadvertent decannulation.
- Ensure thorough preparation before cannula insertion, including verifying the availability of imaging devices, clarifying team roles, and verifying patient-specific anatomical considerations.
- Assemble and prime the ECMO circuit using strict, aseptic techniques. Ensure all connection points are tight.
- Implement processes to reliably identify retained foreign bodies post-procedure.
- Develop pediatric-specific policies and protocols for continuous ECMO monitoring, including frequency of circuit and patient assessment and management of the awake patient.
- Ensure the cannula insertion site is visible through a transparent dressing.
- Document suture integrity and cannula tip position at least daily (e.g., chest radiograph, measurement at the skin) and when concerned about partial dislodgement (UpToDate, 2025).
- If possible, avoid changing the circuit while on ECMO support (Hafezi et al., 2021).
- In cases of complete or partial dislodgement with compromised blood flow, follow these steps:
- Clamp all limbs of the circuit.
- Reduce pump speed.
- Follow emergency circuit clamping measures.
- Control cannula site bleeding, discontinue anticoagulation.
- Replace the cannula with a new cannula.
- Assess blood flow and line pressures.
- Obtain chest radiograph to confirm cannula placement (UpToDate, 2025).
Resources
References
This safety watch is approved for general distribution to improve pediatric safety and reduce patient harm. This safety watch meets the standards of non-identification in accordance with 3.212 of the Patient Safety Quality Improvement Act (PSQIA) and is a permissible disclosure by Child Health PSO. In accordance with our Terms of Use and Code of Conduct, this material cannot be used for any commercial transactions that are unrelated to the original intent of Child Health PSO Patient Safety Action watch.
