Many medical devices and supplies, like catheters and tubes, use a guidewire to help healthcare providers correctly place them in patients’ bodies. Since 2012, the Patient Safety Reporting Program (PSRP) has received 17 reports of unintentionally retained guidewires, 6 of which were submitted in 2020 and 2021. These events were similar to those reported in two recently published articles describing 73 retained guidewires reported to the Joint Commission¹ and 101 reported to the Veterans Health Administration². Both articles found similar contributing factors and root causes as the PSRP reports, including:

• Inexperience or inadequate training

• Inadequate or overlooked policies or procedures

• Policies and procedures not followed

• Interruptions and distractions

• Communication and teamwork

• Supervision

In Oregon, we also found that about half (53%) of the reported retained guidewires occurred during procedures in which a safe procedure checklist was being used. We found that most reported retained guidewires (71%) were not considered to be “countable” by the submitting facility.

Both articles recommend interventions targeting human factors, like checklists and forcing functions (for example, a central line that requires the guidewire be removed to complete insertion). In line with our previous recommendations related to retained objects, we encourage facilities to review their counting policies and include guidewires as “countable” items.

According to the 2017 AORN guidelines (p. 379):

“Establishing a system that accounts for all surgical items opened and used during a procedure constitutes a primary and proactive strategy to prevent patient harm. Reason’s model of human error states that errors involve some kind of deviation from routine practice. The ideal RSI prevention measures are standardized, transparent, verifiable, and reliable. Deliberate, consistent application of and adherence to standardized procedures are necessary to prevent the retention of surgical items.”

Although many guidewires are retained during procedures outside of an operating room, any procedure requiring a guidewire is inherently invasive and should be included in counting policies, regardless of the procedure location.

References

1. Steelman VM, Thenuwara K, Shaw C, Shine L. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Patient Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.003

2. Cherara L, Sculli GL, Paull DE, Mazzia L, Neily J, Mills PD. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf. 2021;17(8):e911-e917. doi:10.1097/PTS.0000000000000475