[Don't always rely on PACS: undetected loss of a central venous catheter guide wire].
A 74-year-old woman had a CVC inserted. Unfortunately, the guide wire was lost under the procedure, and despite a chest X-ray control it was not detected. The reason the guide wire was not identified was insufficient fine-tuning of the >>local<< PC monitor. We recommend regular fine-tuning of monitors used for X-ray control.
Huusom
Jacob
J
Hillerød Sygehus, Anaestesiologisk Afdeling.
Kristensen
Peter Lommer
PL
D000368:Aged; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation; D004868:Equipment Failure; D005260:Female; D005547:Foreign Bodies / Q000000981:diagnostic imaging / Q000209:etiology*; D006801:Humans; D008991:Monitoring, Physiologic / Q000379:methods / Q000592:standards*; D013902:Radiography, Thoracic