Navigation Links
Reports of retained guidewires draw attention to 'never events' in anesthesia
Date:6/20/2013

San Francisco, CA. (June 20, 2013) Retention of guidewires used to place central venous catheters (CVCs) is a complication that is considered always preventablebut nevertheless still happens, according to a report in the July issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS).

Dr Andrea Vannucci and colleagues report their hospital's experience of four patients with retained guidewires, and analyze risk factors for these rare, preventable medical errors. A pair of accompanying editorials support the need for more open discussion of so-called "never events," along with systems approaches to minimize the chances of their occurring.

'Never Events' Should Never HappenBut Still Do

Dr Vannucci and coauthors report on four cases of retained guidewires after CVC placement. Guidewires help in placing CVCs, which are widely used for patient monitoring, fluid or drug administration, and other essential purposes. All four patients underwent CVC placement during complex surgeries such as lung transplantation. The presence of the guidewire was missed on routine postoperative x-rays, and went unrecognized for up to two days after surgery.

Dr Vannucci and colleagues analyzed each case in detail to identify potential contributing factors. Retained guidewires are regarded as "sentinel" safety problem or "never event"they should never occur as long as routine precautions are followed.

All four patients became unstable during surgery, requiring "urgent and complex" procedures. In two cases, there was confusion related to the use of two different guidewires.

Another contributing factor was "inattention blindness" because of the patients' unstable condition, supervising doctors were distracted from ensuring that residents assisting in the operating room followed proper steps in guidewire and CVC placement. "We suggest that distraction of the clinicians and task interruptions resulted in unrecognized deviations from proper technique, which resulted in intravascular guidewire loss," Dr Vannucci and coauthors write.

Even After Precautions, Further Episodes Occur

After the first two cases, steps were introduced to prevent further incidents, including a mandatory training program for residents. Despite these changes, a third event occurred two years later. A "pop-up" reminder regarding guidewire removal was introduced into the electronic medical recordyet the fourth case occurred the following year.

Based on a "root cause analysis," additional preventive measures were introduced, including a checklist to guide every CVC placement. Further training included CVC placement steps to make it less likely for a retained guidewire to be overlooked. "This training recognizes that errors will occur," Dr Vannucci and coauthors write, "but that procedures can be designed to minimize error frequency, decrease the severity of errors when they inevitably occur, and recognize errors before they cause irreversible harm."

In an accompanying editorial by Drs Robert B. Schonenberger and Paul G. Barasch of Yale University School of Medicine applaud the authors' courage in sharing their experience with and response to preventable medical errors. They warn that CVC insertion should never be regarded as a "mundane, routine, or commonplace" technique.

In a separate editorial, Drs Jeffrey Green and John Butterworth of Virginia Commonwealth University emphasize the need to "re-engineer the process" of CVC placement. They conclude, "Only after we adopt systems approaches to counter the failure modes present in many of the high-risk activities in anesthesiology will we begin to move these sentinel events into the 'never' category."


'/>"/>

Contact: Connie Hughes
connie.hughes@wolterskluwer.com
646-674-6348
Wolters Kluwer Health
Source:Eurekalert

Related medicine news :

1. Federal Data Services Hub Does Exist, AISHealth.com Blog Post Reports
2. Long-term study reports deep brain stimulation effective for most common hereditary dystonia
3. Rottenstein Law Group LLP Comments on News Reports of Mirena IUD Side Effects
4. Transvaginal Mesh Lawsuit News: NJ Mesh Consolidation Cases Moving Along, Rottenstein Law Group LLP Reports
5. New Drug Delivery Partnering Terms and Agreements Market Study Report Available at MarketResearchReports.Biz
6. Biomet Hip Lawsuit News: Bernstein Liebhard LLP Reports on Latest Status Conference in Federal Biomet Hip Replacement Litigation
7. Mirena Lawsuit News: Bernstein Liebhard LLP Comments on Mounting Reports of Mirena Side Effects, Including Device Migration, Uterine Perforations
8. NuvaRing Lawsuit News: First New Jersey NuvaRing Trial Scheduled to Start This Week, Rottenstein Law Group LLP Reports
9. Actos Lawsuit News: Plaintiff Claims Actos Causes Bladder Cancer, Rottenstein Law Group LLP Reports
10. Imprelis Lawsuit News: Consumers with Imprelis Tree Damage Must Act before June 28, 2013 to Opt Out of Class-Action Imprelis Lawsuit Settlement, Reports Wright & Schulte
11. China Animal Vaccine Industry 2012-2015 - Market Research Report Available at MarketResearchReports.Biz
Post Your Comments:
*Name:
*Comment:
*Email:
(Date:6/26/2016)... ... June 27, 2016 , ... Quality metrics are proliferating in cancer care, and ... in the eye of the beholder, according to experts who offered insights and commentary ... of Managed Care. For the full issue, click here . , For the ...
(Date:6/26/2016)... ... June 26, 2016 , ... Many women are ... with endometriosis. These women need a treatment plan to not only alleviate symptoms ... can help for preservation of fertility and ultimately achieving a pregnancy. The specialists ...
(Date:6/25/2016)... ... June 25, 2016 , ... First Choice Emergency Room , the largest ... as the Medical Director of its new Mesquite-Samuell Farm facility. , “We are ... Mesquite location,” said Dr. James M. Muzzarelli, Executive Medical Director of First Choice Emergency ...
(Date:6/24/2016)... ... June 24, 2016 , ... A recent article published ... unfamiliar with. The article goes on to state that individuals are now more comfortable ... less common operations such as calf and cheek reduction. The Los Angeles area medical ...
(Date:6/24/2016)... ... June 24, 2016 , ... Global law firm Greenberg Traurig, P.A. announced that ... chosen by their peers for this recognition are considered among the top 2 percent ... special honors as members of this year’s Legal Elite Hall of Fame: Miami ...
Breaking Medicine News(10 mins):
(Date:6/24/2016)... 24, 2016  Arkis BioSciences, a leading innovator ... more durable cerebrospinal fluid treatments, today announced it ... funding is led by Innova Memphis, followed by ... private investors.  Arkis, new financing will accelerate the ... market release of its in-licensed Endexo® technology. ...
(Date:6/23/2016)... DUBLIN , June 23, 2016 ... "Dialysis Devices Global Market - Forecast to 2022" report ... is the treatment method for the patients with kidney failure, ... and excess fluid from the patient,s blood and thus the ... sodium, potassium and chloride in balance. Increasing ...
(Date:6/23/2016)... 23, 2016 Research and Markets ... Market by Type (Organic Chemical (Sugar, Petrochemical, Glycerin), Inorganic ... Coating, Parenteral) - Global Forecast to 2021" report ... The global pharmaceutical excipients market is projected to ... of 6.1% in the forecast period 2016 to 2021. ...
Breaking Medicine Technology: