Wrong size of pulmonary heart valve

Record number: 
MPHO Type: 
Estimated frequency: 
Never reported before to this vigilance programme
Alerting signals, symptoms, evidence of occurrence: 
The day before surgery the pulmonary heart valve was considered too large. New valve with the right size was delivered the same day.
Demonstration of imputability or root cause: 
Communication error. Large size was ordered, but the size in mm has not been specified (25 mm required, 28 mm delivered by tissue establishment).