Preventing Retained Central Venous Catheter Guidewires: A Randomized Controlled Simulation Study Using a Human Factors Approach
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Published on: December 23, 2014
Maryanne Z A Mariyaselvam1, Ken R Catchpole, David K Menon
1From 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.).
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.
