CUED Publications database

Guidewire Retention after Central Venous Catheterisation: Prevention and Mitigation using Bow-Tie Analysis

Ward, JR and Chatzimichailidou, MM and Horberry, T and Teng, Y-C and Clarkson, PJ (2016) Guidewire Retention after Central Venous Catheterisation: Prevention and Mitigation using Bow-Tie Analysis. In: Contemporary Ergonomics and Human Factors 2016, 2016-4-19 to 2016-4-21, Daventry, UK pp. 95-99..

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Abstract

Never events are typically rare but serious incidents in healthcare. They are perceived to be preventable, and include the retention of a surgical instrument in a patient's body. One such instrument is a "guidewire", which is used to help introduce a catheter tube into the venous system of a patient. Following a number of guidewire retentions, these authors investigated contributing factors and examined mechanisms to reduce the risk of further occurrences. This paper presents the results in the form of a bow-tie analysis, which was found to provide an effective way to graphically display and examine the issue.

Item Type: Conference or Workshop Item (UNSPECIFIED)
Uncontrolled Keywords: Bow-tie analysis Guidewire Patient Safety retained foreign object
Subjects: UNSPECIFIED
Divisions: Div C > Engineering Design
Depositing User: Cron Job
Date Deposited: 17 Jul 2017 19:58
Last Modified: 27 Jul 2017 05:31
DOI: