This Signal relates to the risk of retained guidewires in central venous catheters.
A sample incident report reads:
“20cm longline inserted into right ante-cubital fossa. Patient had IV antibiotics as inpatient and outpatient. Patient noticed pain and swelling in right forearm. Firm area (4mm) felt. Tender, skin not broken. Seen by consultant. Oral antibiotics administered. Arm remained tender/swollen, patient had enlarged axillary node. CTPA performed, no evidence of embolism. Ultrasound identified retained guidewire.”
A search of the National Reporting and Learning System (NRLS) identified 46 reports describing that guidewires were inadvertently retained in central venous catheters. Fifteen incidents were reported to have caused severe or moderate harm (1 June 2008 to 1 June 2011) and 31 incidents were reported to have caused low harm or no harm (1 January 2010 to 31 December 2010).
Plymouth Hospitals NHS Trust recently investigated an incident where a guidewire was retained following intravascular line placement. The clinical team investigating the incident identified the following root causes:
· Despite published evidence of incidences of guidewire retention, no formal national guidance has been developed that addresses the issues commonly identified, particularly regarding the humans factors issues involved.
· Line placement is generally considered a single person task, with no standardised process, that includes visual, verbal or documentary confirmation that guidewire has been removed.
· Guidewire removal is reliant on the memory of the operator. This introduces risk, particularly where there are distractions and competing priorities.
To address the issues above the Trust recommends and is currently implementing the following local actions:
· Standardised process for guidewire management during central venous access including:
o two person process (operator and observer);
o visual confirmation of guidewire removal by both persons;
o verbal confirmation of guidewire removal by both persons; and
o documentary confirmation of guidewire removal by both persons
· Training and education to emphasise appropriate control of guidewires.
· Involvement of manufacturers in developing future standard solutions to prevent guidewire retention.
We would like to hear from you - please contact us with your initiatives to reduce risks in these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.