Learning Track: 16. Patient Safety Title: Guidewire retention: reported incidence, location and timing of error Author(s): Mariyaselvam M.1, Walters H.2, Callan C.2, Mathew K.2, Jackman S.2, Young P.3 Institute(s): 1Cambridge University, Dept of Anaesthesiology & Intensive Care, Cambridge, United Kingdom, 2Cambridge University, School of Clinical Medicine, Cambridge, United Kingdom, 3Queen Elizabeth Hospital, Kings Lynn, Dept of Anaesthesiology & Intensive Care, Kings Lynn, United Kingdom Text: Background and Goal of Study: Guidewire retention has been reported at 1:3291 central venous catheter (CVC) insertions, resulting in avoidable harm (1). It is a never event in the UK thereby considered wholly preventable. Human factors interventions, and engineered solutions exist aiming to improve recognition during the procedure. We sought to determine the reported incidence, location and timing of recognition of guide wire retention. Materials and Methods: With institutional IRB approval, NHS England provided confidential data of centrally reported guidewire events (2004-2015) from the National Reporting and Learning System (NRLS) for analysis. Data was sifted, anonymised and provided for classification by 2 independent investigators and adjudicated by a third investigator. Guidewire loss was categorised as recognised during the procedure, recognised on post-procedural X-ray, or missed on X-ray. Location of CVC insertion and annual reporting incidence was also determined. Graph - figure legend: [Annual Incidence of Guidewire Retention] Results and Discussion: Guidewire retention was reported in the ICU (48%), the general ward (25%), the operating room (17%) and other (10%). There were 239 cases identified and 46 excluded for insufficient information reported. The increasing incidence of reported guidewire retention is shown in the figure. There were 25% recognised before the procedure conclusion, 23% were detected by the X-ray and 52% were undetected by both. Conclusion(s): The majority of lost guidewires are forgotten and identified after conclusion of the procedure. For forgotten guidewires, interpretation of an X-ray has poor sensitivity, identifying less than a third of the remaining guidewire retentions. Efforts to avoid guidewire retention should be concentrated on prevention and recognition of forgotten guidewires prior to completion of the procedure when retrieval may be more easily immediately achievable, after this embolisation may occur over time. References: 1. Vannucci A et al. Retained guidewires after intraoperative placement of CVCs. Anesth Analg 2012. Acknowledgements: Helmi Burton-Papp and Quang Nguyen (both of University of Cambridge, School of Clinical Medicine) for contributions to the data analysis. Ethical Research Declaration: 2. Retrospective data review Preferred Presentation Type: Clinical or experimental study
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