title: Guide-wire fragment embolisation in paediatric peripherally inserted central catheters.
abstract: OBJECTIVE
  To report guide-wire fragment embolisation of paediatric peripherally inserted central catheter (PICC) devices and explore the safety profile of four commonly used devices.
  
  
  METHODS
  Clinical incidents involving paediatric PICC devices in Queensland public hospitals were reviewed. A PICC user-experience survey was conducted at five public hospitals with 32 clinicians. A device design evaluation was undertaken, and magnetic resonance imaging (MRI) safety was tested by a simulation study.
  
  
  METHODS
  Embolisation events; technical mistakes, multiple attempts and breakages during insertion; willingness to use the device; failure modes and risk priority rating; movement and/or temperature change on exposure to MRI.
  
  
  RESULTS
  Six clinical incidents of silent guide-wire embolisation, and four near misses were identified; all were associated with one type of device. The survey found that this device had a reported broken-wire embolisation rate of 0.9/100 insertions with no events in other devices; two of the four devices had a higher all-cause embolisation rate (3.3/100 insertions v 0.4/100 insertions) and lower clinician acceptance (68%-71% v 91%-100%). All devices had 6-17 identified failure modes; the two devices that allowed removal of a guide wire through a septum had the highest overall risk rating. Guide-wire exposure to MRI was rated a potential safety risk due to movement.
  
  
  CONCLUSIONS
  There is marked variation in the safety profile of 3 Fr PICC devices in clinical use, and safety performance can be linked to design factors. Pre-MRI screening of all children who have previously had a PICC device inserted is recommended. We advocate a decision-making model for evaluation of device safety.
authors.affiliation: Patient Safety and Quality Improvement Service, Queensland Health, Brisbane, QLD.
authors.forename: Joel M
authors.initials: JM
authors.lastname: Dulhunty
authors.forename: Andreas
authors.initials: A
authors.lastname: Suhrbier
authors.forename: Graeme A
authors.initials: GA
authors.lastname: Macaulay
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Brett
authors.forename: Alexa V A
authors.initials: AV
authors.lastname: van Straaten
authors.forename: Ian M
authors.initials: IM
authors.lastname: Brereton
authors.forename: Jillann F
authors.initials: JF
authors.lastname: Farmer
mesh_terms: D000293:Adolescent; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000295:instrumentation*; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000295:instrumentation*; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D015331:Cohort Studies; D004867:Equipment Design; D004869:Equipment Safety; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D011793:Queensland; D012189:Retrospective Studies; D018570:Risk Assessment; D056824:Upper Extremity Deep Vein Thrombosis / Q000453:epidemiology* / Q000209:etiology*