PERFUSION REPORTS

REPORT

033

DATE

TITLE

Fannin Heparin Ampules Shattering

DETAILS OF INCIDENT

The brand of heparin used in Cardiac Surgery in the hospital was changed. Immediately difficulties were noted opening the new branded ampoules. Two perfusionists received minor cuts and a number of ampoules shattered on opening and others left jagged edges. Glass splinters were observed in a roller pump.

DETAILS OF INJURY TO PATIENT

N/A

TYPE OF DEVICE/MANUFACTURER

N/A

ACTION TAKEN

In excess of 20 ampoules were returned to pharmacy whose initial response was to buy ampoule breakers. Ampoules continued to break unevenly with ampoule breakers and the pharmacy were contacted again.

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Reply From Hospital Pharmacy

"I have highlighted this issue with the All Wales contracting group, and I have also shared this with other pharmacy procurement colleagues across Wales. Cardiff & Vale have also highlighted similar issue with the 20ml ampoules. The suppliers (Kent Pharmaceuticals) have also been contacted, and they are in the process of sourcing new manufacturers in view of the issue with Fannin brand. Once I hear of any update, I will let you know."

RESPONSE FROM MANUFACTURER

N/A

ADDTIONAL INFORMATION

N/A

SUPPORTING VISUALS/VIDEO

N/A

SUPPORTING DOCUMENT

OTHER PERFUSION
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REPORT NO

057



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056



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REPORT NO

055



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

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

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REPORT NO

048



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REPORT NO

047



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REPORT NO

046



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REPORT NO

045



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REPORT NO

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

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REPORT NO

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

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REPORT NO

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

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REPORT NO

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REPORT NO

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

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038

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REPORT NO

037



1/10/17

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REPORT NO

036



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REPORT NO

035



1/10/17

Medtronic Fusion Oxygenator Blood To Gas Leak

REPORT NO

034



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REPORT NO

033



Fannin Heparin Ampules Shattering

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