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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 7/1/2021 12:00:00 AM
Country: Hong Kong
This alert describes a patient safety incident of retention of a foreign body following an invasive procedure. Following the insertion of a central venous catheter (CVC), the suturing sharps were discarded believing they were the guide wire. A subsequent chest X-ray revealed the presence of the guide wire which was then removed. Recommendations to prevent similar incidents are provided

Additional Details

Device:
central venous catheter (CVC), guide wire, suturing sharps

Rules / Policies / Procedures
  1. Reinforce the importance of stringent checking with visual and verbal confirmation of the removed guide wire.
  2. Revisit central venous catheter (CVC) insertion procedural workflow e.g. to discard sharp and guide wire after completing “SIGN OUT”.

Retained Instruments / Material -- Guide Wire