Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events

Retained Surgical Items: Evidence Review and Recommendations for Prevention

“…More than one‐third (35.7%) of the retained guidewires occurred after catheters were inserted for surgery. In 18 events, a portion of the guidewire broke off and was retained; in seven vascular catheter events, the complete guidewire was retained …”

“…Health care facility reporters and The Joint Commission safety specialists identified a total of 285 contributing factors, between 1 and 11 for each report. These were most often human factors (34.4%), leadership (25.3%), and communication (14.7%) . The discovery period was not always specified; when it was specified, only 17.9% of retained guidewires were discovered during the procedure.…”

“…Another study describes 73 instances of unintentionally retained guidewires reported to The Joint Commission. 10 The majority of these events took place during insertion of vascular catheters (86.3%); others took place when the surgeon used a guidewire during a procedure (8.2%). One of the retained guidewires occurred during a breast biopsy with needle localization and another five occurred during knee arthroscopies.…”

“…In 18 events, a portion of the guidewire broke off and was retained; in seven vascular catheter events, the complete guidewire was retained. 10 Health care facility reporters and The Joint Commission safety specialists identified a total of 285 contributing factors, between 1 and 11 for each report. These were most often human factors (34.4%), leadership (25.3%), and communication (14.7%).…”

“…These were most often human factors (34.4%), leadership (25.3%), and communication (14.7%). 10 The discovery period was not always specified; when it was specified, only 17.9% of retained guidewires were discovered during the procedure. Seventeen reports described the migration of the guidewire from the location of insertion.…”