Eliminating Error in Central Line Scheduling and Placement Using Quality Improvement Methods

The Joint Commission defines a sentinel event as "surgery or other invasive procedure performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for a patient regardless of the type of procedure or the magnitude of the outcome." At our institution, we observed a low but consistent rate of incorrect surgical line placement for pediatric patients with cancer.

Following quality improvement methodology and using the resources available on a large academic medical campus, we designed and implemented a new multifactorial process to schedule and place surgical central lines for pediatric patients with cancer. Changes included redefining responsibilities, adding staff, and redesigning the process with workflows supported by modifications to the electronic medical record. Our primary outcome measures were incorrect central line placement or near-miss event per quarter and days between these events.

After implementation, the rate of incorrect line placement and near-miss events was reduced to 0, with 1,018 days since the last incorrect line placement.

As a result of our multifactorial quality improvement initiative in the scheduling and placement of central lines, we were able to eliminate surgical line placement sentinel events and improve care for pediatric patients with cancer.