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.
DETAILS OF INJURY TO PATIENT
None. Occurred on setup.
TYPE OF DEVICE/MANUFACTURER
Medtronic EOPA 24fr Arterial Cannula REF: 77624
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.