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.

Background: Central Venous Catheterisation (CVC) is a medical procedure that has been linked with cases of retained guidewires in a patient after surgery. Whilst this is theoretically a completely avoidable complication, a guidewire of up to 60cm being retained in a patient's vascular system poses a major risk. In recently reported cases, guidewires retained inside patients have not been detected for several years. Aims: The ultimate aim was to develop appropriate, operator-centred safe design solutions that reduce guidewire retention errors. Method: This paper focuses specifically on the application of Nielsen's ten usability heuristics 1 to the issue of retained guidewires. Following the development of a task analysis of the procedure, three researchers (from medical, safety and human factors backgrounds) independently applied the usability heuristics, then met to analyse the findings. Results: A range of usability problems were identified in the Central Venous Catheterisation procedure, and solutions to the identified issues were then proposed: These focused on the design of equipment, or the wider guidewire insertion procedure. The paper details the identified usability problems and possible redesign solutions from the 10 usability heuristics. Conclusion: Overall, the application of the usability heuristics was found to be a useful method both to explore medical device interface problems and to generate possible countermeasures. Further work to eliminate/engineer out the possibility of guidewires being retained is briefly reported.