CUED Publications database

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

Horberry, T and Teng, Y-C and Ward, J and Patil, V and Clarkson, PJ (2014) Guidewire retention following central venous catheterisation: a human factors and safe design investigation. Int J Risk Saf Med, 26. pp. 23-37.

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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.

Item Type: Article
Uncontrolled Keywords: Central venous catheterisation guidewire human factors patient safety safe design Catheterization, Central Venous Central Venous Catheters Equipment Design Equipment Failure Humans Intraoperative Complications Medical Errors Patient Safety
Subjects: UNSPECIFIED
Divisions: Div C > Engineering Design
Depositing User: Cron Job
Date Deposited: 17 Jul 2017 19:06
Last Modified: 14 Sep 2017 01:26
DOI: