Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature.
Objectives: Central venous catheter (CVC) implementation is now usual in emergency department. The most common complications are misplacement, bleeding, pleural perforation, thrombosis and sepsis. Forgetting a guide wire in the patient's body after catheterization is an underestimated complication of this procedure; only 76 cases are described. Even if the majority of patients remained asymptomatic, severe complications can happened even years later. This article's aim is to identify the sequence of elements that led to the event occurrence and to suggest recommendations of good practice to minimize complications related to central catheter placement.Method: After reviewing all the complications related to central venous catheterization and their frequencies, we analyse from a case report and a review of the literature the sequence of elements that led to the medical error. We use an Ishikawa diagram to show our results and the links between them.Results: Our Ishikawa diagram shows that material, human resources, procedural and radiological involvement factors are the main elements on which we can act to reduce the complications rate after central venous catheterization. We advocate for the establishment of standardized procedures before, during and after the technical gesture.Conclusions: Because of human nature, errors will always be possible when taking care of a patient. However, we propose good practice recommendations to avoid the repetition of a forgetting guide wire after central venous catheterization.
['Thonon|Henri|H|https://orcid.org/0000-0003-0760-4109', 'Espeel|Florence|F|', 'Frederic|Ficart|F|', 'Thys|Frédéric|F|']
D000328:Adult D002405:Catheterization, Central Venous D057189:Checklist D005260:Female D005547:Foreign Bodies D015390:Gastric Bypass D006801:Humans D007084:Iliac Vein D008103:Liver Cirrhosis D019300:Medical Errors D012308:Risk Management D014682:Vena Cava, Inferior D014683:Vena Cava, Superior D020246:Venous Thrombosis
emergency department Central catheter checklist human error incident reporting patient safety