Retained Central Venous Catheter Guidewires: Interviews With Clinicians Who Have Made the Error.

Abstract

Objectives: Central venous catheter whole guidewire retention is a serious, preventable patient safety incident that should not occur. Complications include guidewire migration, potentially resulting in cardiac perforation and tamponade. Despite national policy designed to prevent guidewire retention, this error still occurs. Guidewire retention is likely an omission error, however, the precise mechanism of error is unclear: we attempt to clarify why this error occurs.

Methods: Semi-structured interviews were held with 10 clinicians who had made this error. Participants were questioned regarding the day of the error, the retention event, and new safety mechanisms introduced to mitigate future errors. Interview transcripts were analysed using inductive thematic analysis to identify possible contributory factors.

Results: Retention errors occurred with experienced and junior clinicians, complex and routine patients, and in calm or stressful environments. Interruptions and distractions were perceived as commonplace, particularly at the "critical moment" when the catheter is inserted over the guidewire and the guidewire should be removed. Numerous safety checks were used by clinical teams; however, these mostly failed to ensure recognition of retention (4/48 successful recognitions).

Conclusions: Whole guidewire retention occurs in 1:3167 procedures. While training and current policies prevent most whole guidewire retentions, they do not stop the error from occurring and rely on removing human error consistently across thousands of procedures to prevent a single event. A safety-engineered mechanism of error prevention is required that applies to any clinical environment, is impervious to distraction or interruption, and does not rely on clinician memory to ensure guidewire removal.