Confusion increases risk of preventable errors

Retention of guidewires used to place central venous catheters is a preventable complication but nevertheless still happens, U.S. researchers say. Dr. Andrea Vannucci of Washington University School of Medicine in St. Louis and colleagues reported their hospital's experience of four patients with retained guidewires, and analyzed risk factors for these rare, preventable medical errors. Guidewires help in placing central venous catheters, which are widely used for patient monitoring, fluid or drug administration, and other essential purposes. All four patients underwent central venous catheter placement during complex surgeries such as lung transplantation. The study, scheduled to be published in the July issue of Anesthesia & Analgesia, found the presence of the guidewire was missed on routine postoperative X-rays, and went unrecognized for as long as two days after surgery, the study said. Vannucci and colleagues analyzed each case in detail to identify potential contributing factors. Retained guidewires are regarded as a "sentinel" safety problem or "never event" as long as routine precautions are followed, Vanucci said. All four patients became unstable during surgery, requiring "urgent and complex" procedures. In two cases, there was confusion related to the use of two guidewires, the study said. 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 central venous catheter placement. "We suggest that distraction of the clinicians and task interruptions resulted in unrecognized deviations from proper technique, which resulted in intravascular guidewire loss," Vannucci and co-authors wrote in the study.