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Published on: December 23, 2014
Preventing Retained Central Venous Catheter Guidewires: A Randomized Controlled Simulation Study Using a Human
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.).
A novel locked procedure pack prevents retained central venous catheter guidewires. This engineered solution ensures guidewire removal, significantly improving patient safety during catheter insertion procedures.
Area of Science:
- Medical Devices
- Patient Safety
- Surgical Procedures
Background:
- Retained central venous catheter guidewires are critical incidents requiring prevention.
- Current methods rely on human memory, which is prone to failure.
- A novel locked procedure pack was developed to physically prevent guidewire retention.
Purpose of the Study:
- To evaluate the efficacy of a locked procedure pack in preventing retained guidewires.
- To compare the locked pack system against standard practice in a simulated environment.
- To assess clinician acceptance and perceived safety improvements.
Main Methods:
- A randomized controlled forced-error simulation study was conducted.
- Central venous catheter insertion was replicated, with a retained guidewire event introduced.
- Clinicians' ability to discover and resolve the retained guidewire was compared between standard practice and the locked pack.
Main Results:
- The locked pack system successfully prevented guidewire retention in 100% of cases (10/10), compared to 20% (2/10) in standard practice (P < 0.001).
- The inability to access procedure contents in the locked pack group prompted guidewire discovery and removal.
- Clinicians reported improved subjective safety and easier sharps disposal with the locked pack.
Conclusions:
- The locked procedure pack is an effective engineered solution for preventing retained guidewires.
- Forced-error simulation testing confirmed the device's efficacy and clinician acceptability.
- This innovation enhances patient safety in central venous catheter insertion.
