REPORT
038
DATE
Oct 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.

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.  

SUPPORTING VISUALS/VIDEO

See image of cannula attached

SUPPORTING DOCUMENT

OTHER PERFUSION REPORTS

London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Select and scroll to view chosen report
REPORT NO
049
DATE
August 2020
LIVA NOVA RESPONSE TO REPORTED CENTRIFUGAL HEAD ISSUE
REPORT NO
048
DATE
August 2020
Oxygenator Fibre Leak
REPORT NO
047
DATE
May 2020
Failure to remove CO2 effectively
REPORT NO
046
DATE
July 2020
Centrifugal Head Issue 3
REPORT NO
045
DATE
June 2020
Centrifugal Head Issue 2
REPORT NO
044
DATE
Jan 2020
Centrifugal Head Issue
REPORT NO
043
DATE
Feb 2020
Faulty Pressure Relief Valves
REPORT NO
042
DATE
Apr 2020
Leaking ALF
REPORT NO
041
DATE
Feb 2020
Arterial Line Filter Leak
REPORT NO
040
DATE
Mar 2019
Gas Line Filter Issue
REPORT NO
039
DATE
Dec 2019
Dual Lumen Cannula Movement
REPORT NO
038
DATE
Oct 2019
Venous Cannula Damaged
BACK TO SAFETY ARCHIVE