Retained guidewires in central venous catheterisation

An analysis of omission errors

Conference paper (2014)

Authors

Yi Chun Teng University of Cambridge
James R. Ward University of Cambridge
Tim Horberry University of Cambridge
Vishal Patil Cambridge University Hospitals NHS Foundation Trust
P.J. Clarkson University of Cambridge
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Published Date

2014

Language

English

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Abstract

Complete intravascular loss of guidewires in patients is an on-going medical concern. This research investigates the guidewire insertion and removal procedure by using a common omission error model by James Reason to identify procedural disposition to omission errors. The research builds on a previous Hierarchical Task Analysis for central venous catheterisation and identifies two crucial points that need further examination with regard to guidewire loss. Suggestions for improved equipment, procedural and system design at these two task steps are given.