Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events

Area of Science:

• Patient Safety
• Medical Device Complications
• Surgical Errors

Background:

• Unintentionally retained foreign objects are frequently reported sentinel events.
• Guidewires are common retained objects, used to place catheters and other devices.
• Patient safety initiatives aim to reduce retained surgical items.

Purpose of the Study:

• To describe reports of unintentionally retained guidewires.
• To identify contributing factors to guidewire retention.
• To make recommendations for improving patient safety and preventing retained guidewires.

Main Methods:

• Retrospective review of voluntarily reported cases to The Joint Commission (October 2012 - March 2018).
• Analysis of data including device type, insertion site, department, contributing factors, discovery period, and patient harm.
• Inclusion of narrative descriptions for detailed event understanding.

Main Results:

• 73 reports of retained guidewires or parts were reviewed.
• Retention occurred during insertion of vascular catheters, surgical devices, and drainage tubes.
• Top contributing factors included human factors, leadership, and communication.
• 39.3% of guidewires were discovered after hospital discharge.
• 76.7% of cases resulted in unexpected additional care or extended stay.
• Four patient deaths were linked to retained guidewires.

Conclusions:

• Retained guidewires represent a significant and ongoing patient safety concern.
• The complexity of care and numerous contributing factors necessitate targeted interventions.
• Findings provide a basis for developing strategies to prevent guidewire retention and improve patient outcomes.