The image is used as the cover image for the July 2013 issue of Anesthesia and Analgesia. It accompanies the article and editorials summarized here. (Image source: Anesthesia and Analgesia; used with permission)

We use guidewires when inserting large catheters into central veins.  If we’re not careful, we can lose track of them and let them vanish into the cannulated vein. In difficult cases requiring several kits the lost guidewire might be found many hours after catheter insertion.  In the article “Retained Guidewires After Intraoperative Placement of Central Venous Catheters,” published in this month’s issue of Anesthesia and Analgesia, Dr. Andrea Vannucci, (Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri) and co-authors summarized four cases of guidewire loss in their institution between 2006 and 2009 after central venous access procedures.   All of the patients they described had two CVC kits including two guidewires that were used, either because two catheters were to be inserted or because of difficulties inserting a catheter.  When they were finished, the providers might not have realized that a guidewire was missing.  In one instance, a short sheath introducer guidewire was used which was hidden during catheter insertion.  The catheters were inserted shortly after induction in patients who were hemodynamically compromised. That setting, familiar to all of us, naturally distracts provider attention during catheter insertion.

Surprisingly, for all four patients, guidewire retention was not noted in chest radiographs obtained immediately after surgery, in part due to the poor quality of bedside radiographs as well as other wires that are normally present in chests that have been recently instrumented.

The authors’ hospital devised mandatory training for new hospital interns, their anesthesia department instituted a central venous catheter training module for first-year residents and a central venous catheter checklist was adopted and tested.  Yet, two of the four cases of guidewire loss occurred after these changes were implemented.  Now the anesthesia electronic medical record has a pop-up window designed to remind those who use guidewires for catheter insertion to be sure that the guidewire has been removed.  However, the fourth case, a double stick procedure, occurred after this change.  Perhaps that case would not have occurred if there were required guidewire counts.

As Drs. Jeffrey Green and John Butterworth note in one accompanying editorial titled “’Never’ Events: Anesthesiology’s Dirty Little Secret,” “Perhaps instead of counting guidewires at the end of a procedure to ensure they are all accounted for, we could design a process so that only one wire can be on the sterile field at a time. Alternatively we could design better safety systems requiring attachment of a device to the external wire tip as the central line catheter is passed over the wire, obligating the operator to remove the wire at the end of the procedure. Only after we adopt systems approaches to counter the failure modes present in many of the high-risk activities in anesthesiology will we begin to move these sentinel events into the ‘never’ category.”

In a second accompanying editorial entitled “They Did What…?”, Drs. Robert B. Schonberger and Paul G. Barash state that accidents can never be removed from a complex system, complication rates can be minimized if situational awareness is always present, and an electronic medical record can help document events and draw attention to potential safety lapses.  They note that regardless “of how many times we perform the Seldinger technique, it is never mundane, routine, or commonplace. To think so places our patients at extraordinary risk.”

The lesson in these cases is that “never events” can happen to anyone. We practice in one of the world’s most demanding and technically complex environments. Smart, competent, and diligent physicians can and will make “never” mistakes. “Never events” only become never events when we design systems that make them impossible.

CME can be obtained from reading the article and then taking a quiz.