REPORT
035
DATE
Dec 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

ACTION TAKEN

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

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.  

SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

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