PERFUSION REPORTS

REPORT

145

DATE

6/8/2026

TITLE

Disposables: Faulty cardioplegia cannula

DETAILS OF INCIDENT

We have identified a defect with a cardioplegia aortic root cannula. The connector component appears to have separated from the cannula assembly. The affected cannula was identified during use, held together by the surgical team during cardioplegia delivery and retained in case it is required for investigation or return.

DETAILS OF INJURY TO PATIENT

No harm to patient

TYPE OF DEVICE/MANUFACTURER

Ga Cardioplegia Cannula REF: AR-11112 LOT: 2607600045 Size: 9 Fr. LOT/Batch number 2607600045, date of manufacture 2026-03-17, expiry date 2029-03-16.

ACTION TAKEN

The cannula was held together by the surgical team during cardioplegia delivery as it did not seem appropriate to replace at the time by the surgical team. The manufacturer has been contacted and informed of this incident. The cardioplegia cannula was retained to send back to manufacturer's upon their request.

RESPONSE FROM MANUFACTURER

ADDTIONAL INFORMATION

The connector component separated from the cannula assembly during use. The cannula remained functional only because the surgical team manually maintained the connection during cardioplegia delivery.

‍

SUPPORTING VISUALS/VIDEO

SUPPORTING DOCUMENT

OTHER PERFUSION
REPORTS

Select and scroll to view chosen report

REPORT NO

115



13/9/23

Disposable Error/ Eurosets New Born ECMO oxygenator (EU5056) leak

REPORT NO

114



13/7/23

Dispoables: Bonding Solution on Tubing

REPORT NO

113



21/3/23

ERC Failure

REPORT NO

112



20/2/23

HLM Hardware Error: S5 HLM - Dual roller cardioplegia

REPORT NO

111



10/2/23

Human Factors/ Gas leak

REPORT NO

110



31/1/23

DISPOSABLE FAULT

REPORT NO

109



19/1/23

Disposable issue

REPORT NO

108



3/1/23

Disposable issue: Oxygenator leak

REPORT NO

107



6/12/22

Hardware fault. Electronic gas Blender failure

REPORT NO

106



1/11/22

ECG Interference

REPORT NO

105



9/9/22

Issue with use of disposable

REPORT NO

104



13/6/22

Human Factors

REPORT NO

103



25/7/22

Human Factors

REPORT NO

102



7/7/22

Disposable issue

REPORT NO

101



6/4/21

Irregular blood flow/foreign looking substance in Oxygenator

REPORT NO

100



20/4/22

Gas Line Filter Fault

REPORT NO

099



20/4/22

Human Factors: BiVAD Error

REPORT NO

098



4/4/22

REPORT NO

097



19/3/22

Disposables Issue

REPORT NO

096



18/3/22

Bubbles Sensor Activation

REPORT NO

095



1/1/22

Protamine Administration

REPORT NO

094



1/11/21

Oxygenation failure upon commencement of CPB

REPORT NO

093



1/11/21

Detached bullet tip of sump-updated response Sep 2022

REPORT NO

092



1/10/21

Vapourizer Issue

REPORT NO

091



1/10/21

Oyxgenator Leak

REPORT NO

090



1/10/21

Breach of chemical cleaner

REPORT NO

089



1/9/21

Sechrist Gas Blender Sweep on ECMO

REPORT NO

088



1/9/21

Oxygenator High Pressure Events

REPORT NO

087



1/10/21

Leaking one way valve

REPORT NO

086



1/7/21

Electronic Gas Blender Fault

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

145

144

143

142

141

140

139

138

137

136

135

134

133

132

131

130

129

128

127

126

125

124

123

122

121

120

119

118

117

116

115

114

113

112

111

110

109

108

107

106

105

104

103

102

101

100

099

098

097

096

095

094

093

092

091

090

089

088

087

086

085

084

083

082

081

080

079

078

077

076

075

074

073

072

071

070

069

068

067

066

065

064

063

062

061

060

059

058

057

056

055

054

053

052

051

050

049

048

047

046

Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.

USEFUL LINKS

BACK TO SAFETY ARCHIVE SAFETY - SUBMIT A REPORT SAFETY COMMITTEE SAFETY CONTACTS

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Copyright © 2026. The Society of Clinical Perfusion Scientists of Great Britain and Ireland and The College of Clinical Perfusion Scientists of Great Britain and Ireland.

DMCA.com Protection Status

Made With  By MojoPixels‍