Record number:
960
Adverse Occurrence type:
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).
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