Central Venous Catheter Guidewire Retention: Lessons From England’s Never Event Database

Abstract

ObjectivesGuidewire retention during central venous catheter (CVC) insertion is considered a “never event.” We analyzed the National Health Service England Never Event database (2004–2015) to explore the process of guidewire retention and identify potential preventative measures.MethodsWe performed a systematic analysis of reported retained guidewire incidents by 3 independent reviewers.ResultsThere was a rising frequency of reported retained CVC guidewires, with an average of 2 never events per month. Only 11% of retained guidewires are identified during the procedure itself, with the remainder identified during equipment clear-up (6%), after the procedure (4%), at the first check radiograph (23%), or after the first radiograph (55%). In 59 cases, the grade of the operator was reported, and among these, 88% were inserted by trainee doctors. Analysis of causative factors was only possible for 38 cases, and of these, operator’s mistake (32%), operator/human error (16%), and distraction (16%) were the most common. Of 163 reported cases, preventative measures instigated were actions taken against the individual clinician (36%), departmental actions such as investigations, additional teaching or reminders (37%), and additional checklists (27%).ConclusionsMost retained guidewires are discovered after the procedure. Despite the introduction of safety measures, guidewire retention still occurs because the checks, alerts, reminders, and additional checklists all solely rely on the operator remembering not to make the mistake. System changes or design modifications to the CVC equipment are needed to prevent guidewire retention, this being at the top of the hierarchy of intervention effectiveness.

Lost Venous Access Guidewire Identified by Its Late Cervical Protrusion: Case Report

“…Thirteen cases of retained guidewires were reported in the UK Never Events database in 2019. 14 Despite the introduction of safety measures, including checklists, retained guidewires still occur because all preventable measures rely on the operator remembering to perform the safety check. Ultimately, CVC design equipment changes have been proposed to prevent guidewire retention.…”

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

“…We excluded another 337 articles after reviewing the full-text citations largely because they neither identified individual NEs nor specified an existing framework (47%), or because they were non-scholarly (eg, media releases; 30%). Thus, our analyses were based on 367 articles 3 4 7–11 18–377. A full list of these articles and the information we extracted from them are found in online supplemental tables 1 and 2.…”

Removal of a guide-wire sliding into abdominal cavity via transgastric natural orifice transluminal endoscopic surgery: A case report

“…The safe and swift removal of foreign bodies assumes particular significance. Previous reports of guidewire retention predominantly arise from instances where a broken guidewire inadvertently slipped into the bloodstream during procedures such as coronary angiography[ 1 , 7 ]. Unlike those reported cases, the guidewire in the present study was inadvertently left within the abdominal cavity, with only one similar case reported in the literature[ 2 ].…”

“…Guidewires are pivotal in various clinical procedures, encompassing guidance, support, and exchange. While the retention of guidewires within the body is typically deemed uncommon, recent estimates suggest that, on average, two instances of guidewire retention during central venous catheter insertion arise each month[ 1 ]. Nevertheless, only one case involving the retention of guidewires within the abdominal cavity has been previously documented[ 2 ].…”