Abstract
Retained objects are the most frequent harmful error in US hospitals. Central venous catheter insertion requires the use of a guidewire, which the clinician can forget to remove during the procedure. The guidewire can move into the circulation and to the heart and must be retrieved by an invasive surgical procedure, causing upto 20% mortality. Checklists alone depend upon a robust safety culture at all times, with all individuals, in all circumstances and so are only moderately robust and have been shown to fail in complex and disparate healthcare systems. An engineered solution (WireSafe™), forces the clinician to remove a guidewire before they are able to access the equipment required to complete the procedure, this makes this error all but impossible. The WireSafe™ also has design features which facilitates the speed and safety of the routine task which is important when dealing with rare but catastrophic events.
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Mariyaselvam, M., Pearson, D., Heij, R., Fawzy, E., Young, P. (2019). The WireSafe™ for Preventing Retained Central Venous Catheter Guidewires: Clinical Usability. In: Lightner, N. (eds) Advances in Human Factors and Ergonomics in Healthcare and Medical Devices. AHFE 2018. Advances in Intelligent Systems and Computing, vol 779. Springer, Cham. https://doi.org/10.1007/978-3-319-94373-2_27
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DOI: https://doi.org/10.1007/978-3-319-94373-2_27
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