Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign Body on Chest Radiography

Abstract

This article uses a case report and discussion to demonstrate the concept of active and latent failures, and the "systems approach" to the reduction of adverse events in medicine. The case involves an inadvertently misplaced and retained guidewire during femoral vein catheterization using the Seldinger technique, and the subsequent failure to identify the guidewire in the chest despite several chest radiographs and a computed tomography (CT) scan read by radiologists, emergency physicians, and intensivists. This event reveals active failures in the performance of the Seldinger technique, latent failures in the design of the catheter kit, and problems with the current system of interpretation of radiographs. The authors conclude that the design of the catheter kit and the Seldinger technique should be critically examined from a human factors standpoint and that radiographic interpretation is still heavily subject to human error.

A potentially hazardous complication during central venous catheterization: lost guidewire retained in the patient

“…To our knowledge, there are at least 10 published reports of misplaced and retained guidewires during CVC placement [5][6][7][8][9][10][11][12][13][14]. In addition, less than three months before our incident, an affiliated teaching hospital put out an alert about three retained guidewire cases after CVC placement.…”

“…The frequency of these incidents may not be attributable to inadequate training or the operator's lack of skill; rather, it may be due to the inevitability of human error [15]. Thus, to effectively attenuate adverse consequences due to human error, it is useful to critically examine and improve upon the deficiencies in the system itself [10].…”

“…These include creating a guidewire made of a different tactile consistency or coloration for the last few centimeters, a storage ring that is transparent, a tighter fit between guidewire and dilator, and standardization of all kits [10]. Other solutions might include adding a J-tip at the proximal end (the tip not entering the patient) of the wire.…”

“…The holes in this model are caused by active failures and latent conditions [10,16]. Active failures are the mistakes caused by individuals who are in direct contact with the system.…”

“…However, although it may reduce the risk of accidental release, the use of a longer guidewire is not without its potential hazards: it may lead to other complications such as vascular perforation. Previous authors have advocated the use of a checklist to minimize the occurrence of untoward events [10]. Checklists have long been used in the aviation industry (a high-risk field) to guide the pilot through each critical step before takeoff.…”