PERFUSION REPORTS

REPORT

047

DATE

1/12/2019

TITLE

Broken Cannula Dilator

DETAILS OF INCIDENT

On set up by the scrub nurse, the packaging of the cannula was opened and it was reported that when the dilator part of the cannula was being inserted into the cannula by the nurse, the tip of the dilator broke in their hand. This was the second time this occurred.

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DETAILS OF INJURY TO PATIENT

None. Occurred on setup.

TYPE OF DEVICE/MANUFACTURER

Medtronic EOPA 24fr Arterial Cannula REF: 77624

ACTION TAKEN

Straight forward exchange of cannula. Both cannulae were retained and kept for collection and inspection by the manufacturer.

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RESPONSE FROM MANUFACTURER

See letter and image attached.

ADDTIONAL INFORMATION

New action plans/changes as a result of the event?

After discussions with nursing staff and the manufacturer it was decided to give a brief education session to those involved in using the cannula as there were new staff and the dilator may have been used in error.

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SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

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106

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1/11/22

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REPORT NO

105

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REPORT NO

104

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103

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102

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REPORT NO

101



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REPORT NO

100

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REPORT NO

095

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Detached bullet tip of sump-updated response Sep 2022

Perfusion Report cards are shown in batches of 30 at any one time where available.

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