Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events

摘要

Background: Unintentionally retained foreign objects remain the sentinel events most frequently reported to The JointCommission. Many of these objects are guidewires used to facilitate placement of catheters, tubes, and other devices. Thepurpose of this study was to describe reports of unintentionally retained guidewires in order to make recommendations toimprove patient safety.Methods: A retrospective review was undertaken of unintentionally retained guidewires voluntarily reported to The JointCommission from October 2012 through March 2018. Reports included the type of catheter or device, location of insertion,department, contributing factors, discovery period, patient harm, and a narrative description of the event.Results: A total of 73 reports of retained guidewires or parts of guidewires were reviewed. Retention occurred duringinsertion of vascular catheters, devices used during surgery, and drainage tubes. A total of 285 contributing factors wereidentified, most frequently within the categories of human factors , leadership, and communication. In the cases in which thediscovery period was known, 39.3% were identified after hospital discharge. In 76.7% of reports, the harm was categorizedas unexpected additional care or extended stay. Four patients died as a result of the retained guidewire.Conclusion: Unintentionally retained guidewires remain a significant patient safety issue. This study describes retainedguidewires used to insert a variety of vascular catheters and devices, in different departments within hospitals. The largenumber of contributing factors demonstrates the complexity of care and provides new knowledge that can be used fordesigning interventions for prevention.