PERFUSION REPORTS

REPORT

050

DATE

1/10/2019

TITLE

Venous Cannula Damaged

DETAILS OF INCIDENT

After coming off CPB, the venous cannula was clamped (for the first time) whilst checking the echo results. The patient had small volume requirements that were transfused from the pump. The patient suddenly became profoundly hypovolemic and blood was noticed to be dripping on the OR floor. The surgical tubing clamp had cut through the cannula and the patient was losing volume from this. It was re-clamped, removed and returned and reported to the company. On expection, the cannula was powdery and brittle.

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DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Sorin 12F Paediatric Venous Cannula

Product Code: V900-142

Lot: 1809120049

ACTION TAKEN

Reported to the company and the cannula was kept and returned for further investigation.

RESPONSE FROM MANUFACTURER

Awaiting official response

ADDTIONAL INFORMATION

Upon reflection what do you think went well?

Communication went well. Response to the problem was swift and acted upon quickly, thus preventing extra exposure to blood products. Even though the main people involved with this patients care were experienced senior staff, this was something which they all had not come across before and was therefore unexpected.

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

No new action plans. The feedback to all members of the team and family were appreciated.

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SUPPORTING VISUALS/VIDEO

See image of cannula attached

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SUPPORTING DOCUMENT

038 Broken Cannula