Single or Multiple Incident:
10/1/2020 12:00:00 AM
This alert describes a patient safety incident of retention of a foreign body during an invasive procedure. A patient requiring intubation and resuscitation had a central venous catheter (CVC) inserted for administration of inotropes. After 2 attempts of insertion, the attending doctor confirmed the placement of CVC. The patient developed an electrocardiogram change and adrenalin was administered. A nurse asked whether the guide wire had been removed. It was found that a guide wire was placed inside the sharps box and a question was raised as to whether it was the one just used. Meanwhile, an urgent chest X-ray was taken. A retained CVC guide wire was identified w. hile reviewing the X-ray. The guide wire was removed by interventional radiology. Contributing factors and recommendations to prevent similar incidents are provided in the alert .
dressing set, suture set, sharps box
0.9% sodium chloride (normal saline)
inotropic medications, IV ,
adrenergic agonists, IV
Retained Instruments / Material – Central Venous Catheter (CVC) Guide Wire