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BackgroundFrom January to October 2017, several departments of our hospital reported incidents involving paediatric central venous catheters (3–4 Fr) that led to invasive interventions on patients, in some cases even after their repairi by a dedicated kit. The pharmacist reported to the Ministry of Health each of the cases that occurred, communicating at the same times the events to the manufacturer and the hospital health department. A number of meetings were organised with the various departments involved, with the supplier company and with our Hospital Clinical Risk Department.PurposeThe goal was to understand the problem that led to device breaks and to create a shared pathway in order to replace them with others with characteristics that best met our needs.Material and methodsCollecting incident reports.Organising meetings with the departments involved, the manufacturer providing the device and the Clinical Risk Department.ResultsDuring the period under review there were 16 incidents with children aged between 3 months to 10 years, mainly in the departments of Oncoematology, Neonatal Intensive Care Unit, Department of Blood and Marrow Transplantation, Operating Room and Nutritional Service. Central venous catheters were used to administer chemotherapy therapies and parenteral nutrition: each one was withdrawn by the manufacturer to make the necessary investigations. Abandoning the hypothesis that the material was not suitable for the administration of certain chemotherapeutic drugs and that the problem was related to specific batches of the device itself, the decision taken by the clinicians, in accordance with pharmacists and clinical risk managers, was to replace the product, due to the number of accidents that had occurred in a few months.ConclusionThis experience demonstrates how the surveillance system is effective in responding to clinical needs when there is a strong collaboration among all involved actors.No conflict of interest