By Alexis Reeves, RN, CPHRM, CLNC, Interim Director of Patient Safety Operations
When we hear the words unintentionally retained foreign objects (URFO), what comes to mind are the surgical sponges and instruments inadvertently left in a body cavity after surgery. Today, guidewires left behind from starting central lines are a more likely scenario.
Due to the focus on early treatment of sepsis, more central lines are being inserted than ever before. Much of the time, patients being admitted for sepsis require immediate treatment, placing urgency onto the physicians inserting the central lines. When you look at the Root Cause Analysis (RCA) of many of these cases, the emergent nature of the procedure is at the heart of the issue. When treating patients who are decompensating, physicians feel pressure to react quickly to save a life.
Stanford Health Care is no exception to the vulnerability of unintended retention of guidewires. The patients at Stanford are often critically ill, requiring procedures and medication that rely on the insertion of central lines. Due to the identified need to review current practices at Stanford, a multidisciplinary group of physicians and nurses embarked on performing a Failure Mode Effects Analysis (FMEA) in Prevention of Retained Guidewires.
The FMEA is a proactive and systematic effort to identify failures among each process step along the workflow, and highlight opportunities to build in redundant processes that would prevent failures that can lead to patient harm. It was obvious early on to the FMEA team that the guidewires were being retained after the inserter let go of the wire during insertion. The challenge was to discover why this was occurring.
As an academic medical center that trains hundreds of residents per year, Stanford is not unique in such challenges. The California Hospital Patient Safety Organization (CHPSO) found as part of its investigation that guidewires were not being secured in one hand while the other hand advanced the catheter over the wire. The report cited the lack of experience of the inserters as one of the causes. Stanford's Failure Mode Effects Analysis identified several contributing factors including lack of standardized education for the insertion of central lines, lack of experience on the part of the inserter, lack of process in accounting for the guidewires and lack of standardized central line kits.
Standardizing education is difficult to control as residents come with varying levels of experience and training. Of the two cases investigated by the committee, both involved residents who were inserting the line in an emergent situation who simply let go of the wire. The FMEA team discovered that multiple issues played a role in the guidewire retention, including the experience level of the resident, the emergent nature of the patient and the middle of the night occurrence. In one case, it was a perfect storm of factors that led to the guidewire retention – the patient was critical, it was the middle of the night, the resident had limited experience and the central line needed to be placed emergently. Luckily, the resident immediately identified the issue and the patient was taken to the Interventional Radiology Lab where physicians were able to snare the guidewire causing no harm to the patient. No patient harm has occurred due to retention of guidewires at Stanford, but the potential is there and must be addressed through proactive processes.
Having identified the gaps in the process of central line insertion, the FMEA team is working to standardize education, improve communication, assure the appropriate experience level of the inserter and reconcile the guidewires. The partnership of the multidisciplinary group of physicians and nurses is critical to preventing future retained guidewires. The efforts of these dedicated physicians and nurses to continually look for ways to improve the complex system will continue to assure the safety of the patients. Just remember, don't let go!