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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

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

Rules / Policies / Procedures
  1. Develop a departmental protocol for CVC insertion to standardise the procedure steps and role delineation of each team member.
  2. Collect guidewire(s) and check integrity before performing suture.
Training
  1. An eCourse is newly introduced to the eLC platform. The eLC eCourse can be accessed by this hyperlink (with quiz after viewing the long video): “Safety Precautions in Central Venous Catheter Insertion”

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