title: Guidewire retention following central venous catheterisation: a human factors and safe design investigation.
abstract: BACKGROUND
  Central Venous Catheterisation (CVC) has occasionally been associated with cases of retained guidewires in patients after surgery. In theory, this is a completely avoidable complication; however, as with any human procedure, operator error leading to guidewires being occasionally retained cannot be fully eliminated.
  
  
  OBJECTIVE
  The work described here investigated the issue in an attempt to better understand it both from an operator and a systems perspective, and to ultimately recommend appropriate safe design solutions that reduce guidewire retention errors.
  
  
  METHODS
  Nine distinct methods were used: observations of the procedure, a literature review, interviewing CVC end-users, task analysis construction, CVC procedural audits, two human reliability assessments, usability heuristics and a comprehensive solution survey with CVC end-users.
  
  
  RESULTS
  The three solutions that operators rated most highly, in terms of both practicality and effectiveness, were: making trainees better aware of the potential guidewire complications and strongly emphasising guidewire removal in CVC training, actively checking that the guidewire is present in the waste tray for disposal, and standardising purchase of central line sets so that differences that may affect chances of guidewire loss is minimised.
  
  
  CONCLUSIONS
  Further work to eliminate/engineer out the possibility of guidewires being retained is proposed.
authors.affiliation: Engineering Design Centre, Department of Engineering, University of Cambridge, Cambridge, UK Minerals Industry Safety and Health Centre, University of Queensland, Brisbane, Australia.
authors.forename: Tim
authors.initials: T
authors.lastname: Horberry
authors.affiliation: Engineering Design Centre, Department of Engineering, University of Cambridge, Cambridge, UK.
authors.forename: Yi-Chun
authors.initials: YC
authors.lastname: Teng
authors.affiliation: Engineering Design Centre, Department of Engineering, University of Cambridge, Cambridge, UK.
authors.forename: James
authors.initials: J
authors.lastname: Ward
authors.affiliation: Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
authors.forename: Vishal
authors.initials: V
authors.lastname: Patil
authors.affiliation: Engineering Design Centre, Department of Engineering, University of Cambridge, Cambridge, UK.
authors.forename: P John
authors.initials: PJ
authors.lastname: Clarkson
mesh_terms: D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000295:instrumentation; D062905:Central Venous Catheters / Q000009:adverse effects / Q000592:standards; D004867:Equipment Design; D004868:Equipment Failure; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology / Q000517:prevention & control; D019300:Medical Errors / Q000517:prevention & control*; D061214:Patient Safety
keywords: Central venous catheterisation; guidewire; human factors; patient safety; safe design