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 26, 2016 , ... PawPaws brand pet supplements ... was developed to enhance the health of felines. The formula is all-natural and is ... herbs in the PawPaws Cat Kidney Support Supplement Soft Chews are Astragalus ...
(Date:6/25/2016)... , ... June 25, 2016 , ... Austin residents seeking ... American College of Mohs Surgery and to Dr. Russell Peckham for medical and surgical ... effective treatment for skin cancer. The selective fellowship in Mohs Micrographic Surgery completed by ...
(Date:6/25/2016)... ... June 25, 2016 , ... As a lifelong Southern Californian, Dr. Omkar Marathe ... from the David Geffen School of Medicine at UCLA. He trained in Internal Medicine ... his fellowship in hematology/oncology at the UCLA-Olive View-Cedars Sinai program where he had the ...
(Date:6/24/2016)... , ... June 24, 2016 , ... A recent ... most people are unfamiliar with. The article goes on to state that individuals are ... many of these less common operations such as calf and cheek reduction. The Los ...
(Date:6/24/2016)... ... June 24, 2016 , ... The Pulmonary Hypertension Association (PHA) ... will receive two significant new grants to support its work to advance research ... anniversary by recognizing patients, medical professionals and scientists for their work in fighting ...
Breaking Medicine News(10 mins):
(Date:6/24/2016)... -- Research and Markets has announced the addition ... report to their offering. ... The World Market for Companion Diagnostics covers the world ... in the report includes the following: , ... by Region (N. America, EU, ROW), 2015-2020 , World ...
(Date:6/23/2016)... 2016  MedSource announced today that it has ... solution of choice.  This latest decision demonstrates MedSource,s ... their clients by offering a state-of-the-art electronic data ... nowEDC as the EDC platform of choice in ... "nowEDC has long been a preferred EDC platform ...
(Date:6/23/2016)... INDIANAPOLIS , June 23, 2016 Roche ... received 510(k) clearance for its Elecsys BRAHMS PCT (procalcitonin) ... severe sepsis or septic shock. With this clearance, Roche ... provide a fully integrated solution for sepsis risk assessment ... associated with bacterial infection and PCT levels in blood ...
Breaking Medicine Technology: