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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 4/1/2021 12:00:00 AM
Country: Hong Kong

This alert describes a patient safety incident of retention of a foreign body. An emergency operation was arranged and a triple lumen central venous catheter (CVC) was inserted into the right internal jugular vein by an anaesthetist. The procedure was assisted by circulating nurse A under the supervision of nurse B, who was simultaneously assisting in instrument counting with the scrub nurse. Nurse A was called to support another operating room after having prepared the necessary items for the CVC procedure. Before completion of the emergency operation, nurse B found that the trolley for the CVC insertion had been set aside and all the sharp items had been cleared. Nurse B assumed that the guide wire had also been disposed of by the anaesthetist. Post-operation chest X-ray revealed the guide wire within the lumen of the CVC along the RIGHT internal jugular vein. Guide wire was removed together with the CVC eventually. Contributing factors and recommendations to prevent similar incidents are provided. In addition, safety precautionary statements are provided relative to CVC insertion.

Additional Details

guidewire, central venous catheter (CVC)

Retained Instruments / Material - Guide Wire