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

d 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."


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

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