Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety

Area of Science:

• Medical Devices
• Emergency Medicine
• Patient Safety

Background:

• Small-caliber chest tubes are frequently used for pneumothorax and pleural effusions.
• Despite being considered less invasive, these tubes exhibit a high complication rate.
• Emergency physicians require a systematic approach to manage complications and device malfunctions.

Purpose of the Study:

• To identify and analyze complications associated with small-caliber chest tubes, specifically pigtail catheters.
• To investigate contributing factors to device malfunction using root cause analysis (RCA).
• To highlight opportunities for improving patient safety in percutaneous catheter procedures.

Main Methods:

• Literature review of small-caliber chest tube complications.
• Analysis of U.S. Food and Drug Administration (FDA) reports for a specific pigtail catheter kit.
• Structured root cause analysis (RCA) of two cases involving retained obturators.

Main Results:

• Common pigtail catheter complications were identified from medical literature.
• Twenty-eight FDA reports detailed kit complications; retained obturator errors were unique to the analyzed cases.
• RCA revealed contributing factors including radiographic clues, human error, communication issues, and device design.

Conclusions:

• RCA identified preventable errors in pigtail catheter insertion, emphasizing the need for improved patient safety.
• Enhanced provider education, systematic procedural approaches, and device design improvements can mitigate risks.
• An end-of-procedure time-out and systematic device assessment are crucial patient safety measures.