Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events

Unintentionally retained foreign objects remain the sentinel events most frequently reported to The Joint Commission. Many of these objects are guidewires used to facilitate placement of catheters, tubes, and other devices. The purpose of this study was to describe reports of unintentionally retained guidewires in order to make recommendations to improve patient safety.

A retrospective review was undertaken of unintentionally retained guidewires voluntarily reported to The Joint Commission from October 2012 through March 2018. Reports included the type of catheter or device, location of insertion, department, contributing factors, discovery period, patient harm, and a narrative description of the event.

A total of 73 reports of retained guidewires or parts of guidewires were reviewed. Retention occurred during insertion of vascular catheters, devices used during surgery, and drainage tubes. A total of 285 contributing factors were identified, most frequently within the categories of human factors, leadership, and communication. In the cases in which the discovery period was known, 39.3% were identified after hospital discharge. In 76.7% of reports, the harm was categorized as unexpected additional care or extended stay. Four patients died as a result of the retained guidewire.

Unintentionally retained guidewires remain a significant patient safety issue. This study describes retained guidewires used to insert a variety of vascular catheters and devices, in different departments within hospitals. The large number of contributing factors demonstrates the complexity of care and provides new knowledge that can be used for designing interventions for prevention.