Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.
This article uses a case report and discussion to demonstrate the concept of active and latent failures, and the "systems approach" to the reduction of adverse events in medicine. The case involves an inadvertently misplaced and retained guidewire during femoral vein catheterization using the Seldinger technique, and the subsequent failure to identify the guidewire in the chest despite several chest radiographs and a computed tomography (CT) scan read by radiologists, emergency physicians, and intensivists. This event reveals active failures in the performance of the Seldinger technique, latent failures in the design of the catheter kit, and problems with the current system of interpretation of radiographs. The authors conclude that the design of the catheter kit and the Seldinger technique should be critically examined from a human factors standpoint and that radiographic interpretation is still heavily subject to human error.
Department of Emergency Medicine, University of Rochester, University of Rochester School of Medicine, NY 14642, USA.
Timothy E
TE
Lum
Rollin J
RJ
Fairbanks
Elliot C
EC
Pennington
Frank L
FL
Zwemer
D000328:Adult; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation*; D003951:Diagnostic Errors; D004635:Emergency Medicine / Q000295:instrumentation / Q000379:methods; D004868:Equipment Failure; D005260:Female; D005268:Femoral Vein; D005547:Foreign Bodies / Q000000981:diagnostic imaging* / Q000209:etiology* / Q000628:therapy; D006801:Humans; D011654:Pulmonary Edema / Q000209:etiology; D011655:Pulmonary Embolism / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy; D013902:Radiography, Thoracic; D016896:Treatment Outcome; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging*