Perioperative Medicine  |   October 2017
Preventing Retained Central Venous Catheter Guidewires: A Randomized Controlled Simulation Study Using a Human Factors Approach
Author Notes
  • From the Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom (M.Z.A.M., D.K.M.); Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina (K.R.C.); Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge, United Kingdom (A.K.G.); and Critical Care Department, The Queen Elizabeth Hospital, Kings Lynn, United Kingdom (P.J.Y.).
  • Submitted for publication January 3, 2017. Accepted for publication June 22, 2017.
    Submitted for publication January 3, 2017. Accepted for publication June 22, 2017.×
  • This article is featured in “This Month in Anesthesiology,” page 1A.
    This article is featured in “This Month in Anesthesiology,” page 1A.×
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    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Address correspondence to Dr. Mariyaselvam: Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0SP, United Kingdom. m.mariyaselvam@nhs.net. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Clinical Science / Patient Safety / Technology / Equipment / Monitoring
Perioperative Medicine   |   October 2017
Preventing Retained Central Venous Catheter Guidewires: A Randomized Controlled Simulation Study Using a Human Factors Approach
Anesthesiology 10 2017, Vol.127, 658-665. doi:10.1097/ALN.0000000000001797
Anesthesiology 10 2017, Vol.127, 658-665. doi:10.1097/ALN.0000000000001797
Abstract

Background: Retained central venous catheter guidewires are never events. Currently, preventative techniques rely on clinicians remembering to remove the guidewire. However, solutions solely relying upon humans to prevent error inevitably fail. A novel locked procedure pack was designed to contain the equipment required for completing the procedure after the guidewire should have been removed: suture, suture holder, and antimicrobial dressings. The guidewire is used as a key to unlock the pack and to access the contents; thereby, the clinician must remove the guidewire from the patient to complete the procedure.

Methods: A randomized controlled forced-error simulation study replicated catheter insertion. We created a retained guidewire event and then determined whether clinicians would discover it, comparing standard practice against the locked pack.

Results: Guidewires were retrieved from 2/10 (20%) standard versus 10/10 (100%) locked pack, n = 20, P < 0.001. In the locked pack group, participants attempted to complete the procedure; however, when unable to access the contents, this prompted a search for the key (guidewire). Participants discovered the guidewire within the catheter lumen, recovered it, utilized it to unlock the pack, and finish the procedure. A structured questionnaire reported that the locked pack also improved subjective safety of central venous catheter insertion and allowed easy disposal of the sharps and guidewire (10/10).

Conclusions: The locked pack is an engineered solution designed to prevent retained guidewires. Utilizing forced-error simulation testing, we have determined that the locked pack is an effective preventative device and is acceptable to clinicians for improving patient safety.