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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 10/1/2020 12:00:00 AM
Country: Hong Kong

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 .

Additional Details

dressing set, suture set, sharps box
inotropes, adrenalin, epinehrine, 0.9% sodium chloride (normal saline)
Medication/IV List:
inotropic medications, IV , adrenergic agonists, IV

Retained Instruments / Material – Central Venous Catheter (CVC) Guide Wire