A novel locked procedure pack was designed to contain the equipment required for completing the procedure after the guidewire should have been removed: suture, suture holder, and antimicrobial dressings” Mariyaselvam et al (2017).
BACKGROUND: Retained central venous catheter guidewires are never events. Currently, preventative techniques rely on clinicians remembering to remove the guidewire. However, solutions solely relying upon humans to prevent error inevitably fail. A novel locked procedure pack was designed to contain the equipment required for completing the procedure after the guidewire should have been removed: suture, suture holder, and antimicrobial dressings. The guidewire is used as a key to unlock the pack and to access the contents; thereby, the clinician must remove the guidewire from the patient to complete the procedure.
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METHODS: A randomized controlled forced-error simulation study replicated catheter insertion. We created a retained guidewire event and then determined whether clinicians would discover it, comparing standard practice against the locked pack.
RESULTS: Guidewires were retrieved from 2/10 (20%) standard versus 10/10 (100%) locked pack, n = 20, P < 0.001. In the locked pack group, participants attempted to complete the procedure; however, when unable to access the contents, this prompted a search for the key (guidewire). Participants discovered the guidewire within the catheter lumen, recovered it, utilized it to unlock the pack, and finish the procedure. A structured questionnaire reported that the locked pack also improved subjective safety of central venous catheter insertion and allowed easy disposal of the sharps and guidewire (10/10).
CONCLUSIONS: The locked pack is an engineered solution designed to prevent retained guidewires. Utilizing forced-error simulation testing, we have determined that the locked pack is an effective preventative device and is acceptable to clinicians for improving patient safety.
Mariyaselvam, M.Z.A., Catchpole, K.R., Menon, D.K., Gupta, A.K. and Young, P.J. (2017) Preventing Retained Central Venous Catheter Guidewires: A Randomized Controlled Simulation Study Using a Human Factors Approach. Anesthesiology. August 11th. .
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