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Guide wire loss after central venous catheterization: a preventable complication!
Journal of Clinical Anesthesia (2015) xx, xxx–xxx
Guide wire loss after central venous catheterization: a preventable complication! To the Editor: We read the, “Case report of a guide wire loss and migration after central venous access,” by Van Doninck et al [1] in the August 2015 edition of the Journal of Clinical Anesthesia. We have few comments about the case. There have been numerous reports of the loss of a guide wire during central venous cannulation [2,3]. Human errors are inherent and may happen more commonly in teaching hospitals due to the involvement of multiple providers, including trainees, for a single patient [4]. There is evidence that standard protocols including time-outs and checklists may assist with decreasing the number of preventable errors [5]. At our previous institution, there was a prescribed safety measurement for all central venous cannulation procedures. Before the start of the procedure, a time-out would be called. During the procedure, the person performing the cannulation would call “guide wire out” once the guide wire had been removed and such a note would be made on the checklist for the procedure. We would recommend having a time-out and checklist for this procedure including calling “guide wire out” for central venous cannulation, which may help prevent such complications from occurring in the future, therefore improving patient safety.
0952-8180/© 2015 Elsevier Inc. All rights reserved.
Praveen Maheshwari MD* Parul Maheshwari MD Department of Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA *Corresponding author at: Department of Anesthesiology University of Oklahoma Health Sciences Center 750 N.E. 13th Street, Suite OAC200 Oklahoma City, OK 73014, USA Tel.: +1-405-271-4531; fax: 1-405-271-8695 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.07.018
References [1] Van Doninck J, Maleux G, Coppens S, Moke L. Case report of a guide wire loss and migration after central venous access. J Clin Anesth 2015 Aug;27(5):406-10. [2] Gulel O, Soylu K, Yuksel S, Keceligil HT, Akcay M. A forgotten guidewire causing intracardiac multiple thrombi with paradoxical and pulmonary embolism. Can J Cardiol 2013;29(6):751.e15-6. http://dx. doi.org/10.1016/j.cjca.2012.12.010. [3] Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: mishap or blunder? Br J Anaesth 2002 Jan;88(1):144-6. [4] Ashcroft DM, Lewis PJ, Tully MP, Farragher TM, Taylor D, Wass V, et al. Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. Drug Saf 2015. http://dx.doi.org/10.1007/s40264-015-0320-x [Epub ahead of print]. [5] Wilson I, Walker I. The WHO surgical safety checklist: the evidence. J Perioper Pract 2009;19(10):362-4.
Guide wire loss after central venous catheterization: a preventable complication! To the Editor: We read the, “Case report of a guide wire loss and migration after central venous access,” by Van Doninck et al [1] in the August 2015 edition of the Journal of Clinical Anesthesia. We have few comments about the case. There have been numerous reports of the loss of a guide wire during central venous cannulation [2,3]. Human errors are inherent and may happen more commonly in teaching hospitals due to the involvement of multiple providers, including trainees, for a single patient [4]. There is evidence that standard protocols including time-outs and checklists may assist with decreasing the number of preventable errors [5]. At our previous institution, there was a prescribed safety measurement for all central venous cannulation procedures. Before the start of the procedure, a time-out would be called. During the procedure, the person performing the cannulation would call “guide wire out” once the guide wire had been removed and such a note would be made on the checklist for the procedure. We would recommend having a time-out and checklist for this procedure including calling “guide wire out” for central venous cannulation, which may help prevent such complications from occurring in the future, therefore improving patient safety.
0952-8180/© 2015 Elsevier Inc. All rights reserved.
Praveen Maheshwari MD* Parul Maheshwari MD Department of Anesthesiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA *Corresponding author at: Department of Anesthesiology University of Oklahoma Health Sciences Center 750 N.E. 13th Street, Suite OAC200 Oklahoma City, OK 73014, USA Tel.: +1-405-271-4531; fax: 1-405-271-8695 E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2015.07.018
References [1] Van Doninck J, Maleux G, Coppens S, Moke L. Case report of a guide wire loss and migration after central venous access. J Clin Anesth 2015 Aug;27(5):406-10. [2] Gulel O, Soylu K, Yuksel S, Keceligil HT, Akcay M. A forgotten guidewire causing intracardiac multiple thrombi with paradoxical and pulmonary embolism. Can J Cardiol 2013;29(6):751.e15-6. http://dx. doi.org/10.1016/j.cjca.2012.12.010. [3] Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: mishap or blunder? Br J Anaesth 2002 Jan;88(1):144-6. [4] Ashcroft DM, Lewis PJ, Tully MP, Farragher TM, Taylor D, Wass V, et al. Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. Drug Saf 2015. http://dx.doi.org/10.1007/s40264-015-0320-x [Epub ahead of print]. [5] Wilson I, Walker I. The WHO surgical safety checklist: the evidence. J Perioper Pract 2009;19(10):362-4.