Guidewire retention following central venous catheterisation: a human factors and safe design investigation

Horberry, Tim, Teng, Yi-Chun, Ward, James, Patil, Vishal and Clarkson, P. John (2014) Guidewire retention following central venous catheterisation: a human factors and safe design investigation. International Journal of Risk and Safety in Medicine, 26 1: 23-37. doi:10.3233/JRS-140610


Author Horberry, Tim
Teng, Yi-Chun
Ward, James
Patil, Vishal
Clarkson, P. John
Title Guidewire retention following central venous catheterisation: a human factors and safe design investigation
Journal name International Journal of Risk and Safety in Medicine   Check publisher's open access policy
ISSN 0924-6479
1878-6847
Publication date 2014-05-05
Sub-type Article (original research)
DOI 10.3233/JRS-140610
Volume 26
Issue 1
Start page 23
End page 37
Total pages 15
Place of publication Amsterdam, Netherlands
Publisher I O S Press
Language eng
Formatted abstract
BACKGROUND: Central Venous Catheterisation (CVC) has occasionally been associated with cases of retained guidewires in patients after surgery. In theory, this is a completely avoidable complication; however, as with any human procedure, operator error leading to guidewires being occasionally retained cannot be fully eliminated.

OBJECTIVE: The work described here investigated the issue in an attempt to better understand it both from an operator and a systems perspective, and to ultimately recommend appropriate safe design solutions that reduce guidewire retention errors.

METHODS: Nine distinct methods were used: observations of the procedure, a literature review, interviewing CVC end-users, task analysis construction, CVC procedural audits, two human reliability assessments, usability heuristics and a comprehensive solution survey with CVC end-users.

RESULTS: The three solutions that operators rated most highly, in terms of both practicality and effectiveness, were: making trainees better aware of the potential guidewire complications and strongly emphasising guidewire removal in CVC training, actively checking that the guidewire is present in the waste tray for disposal, and standardising purchase of central line sets so that differences that may affect chances of guidewire loss is minimised.

CONCLUSIONS: Further work to eliminate/engineer out the possibility of guidewires being retained is proposed.
Keyword Central venous catheterisation
Guidewire
Patient safety
Human factors
Safe design
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Minerals Industry Safety and Health Centre Publications
Official 2015 Collection
 
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Created: Sat, 10 May 2014, 00:06:48 EST by Dr Tim Horberry on behalf of Minerals Industry Safety and Health Centre