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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 7/1/2020 12:00:00 AM
Country: Hong Kong
This alert describes a patient safety incident of retention of a foreign body following a surgical procedure. A 62-day-old baby with biliary atresia underwent Kasai operation. A peripherally inserted central catheter (PICC) was inserted under anaesthesia under ultrasound guidance. The first attempt at RIGHT arm was not successful. The second attempt at RIGHT ankle was aborted due to unsmooth guide wire insertion. The anaesthetist cut away the distal 2 cm of the guide wire due to contamination during insertion. During the third attempt at the LEFT ankle, the anaesthetist cut away the J-tip because it was deformed. The PICC was inserted successfully. After the surgery the total length of the 3 segments of guide wire were checked and deemed compatible with the original length of the guide wire and the surface was smooth. A post-operative abdominal X-ray revealed a radio-opaque line inside the PICC. The PICC with the foreign body were completely removed under image intensifier guidance. The foreign body was confirmed to be the external sheath of the PICC guide wire without its internal core. Core had been pulled out and was interpreted as the guide wire in whole. Contributing factors and recommendations to prevent similar incidents are provided.

Additional Details

Device:
peripherally inserted central catheter (PICC)

Environment / Equipment
  1. Guide wire must not be cut during the insertion of central venous catheter. It is recommended to change to a new set if needed.
Training
  1. Alert staff about possible outcome if guide wire was cut, and arouse their awareness when checking the guide wire after procedures.

Retained Instruments / Material -- Sheath of Guide Wire