Guidewire Retention after Central Venous Catheterisation: Prevention and Mitigation using Bow-Tie Analysis

James Ward, Maria Mikela Chatzimichailidou, Tim Horberry, Yi-Chun Teng, John Clarkson

Research output: Chapter in Book/Report/Conference proceedingConference PaperResearchpeer-review

Abstract

Never events are typically rare but serious incidents in healthcare. They are
perceived to be preventable, and include the retention of a surgical instrument in a
patient's body. One such instrument is a "guidewire", which is used to help introduce a catheter tube into the venous system of a patient. Following a number of guidewire retentions, these authors investigated contributing factors and examined mechanisms to reduce the risk of further occurrences. This paper presents the results in the form of a bow-tie analysis, which was found to provide an effective way to graphically display and examine the issue.
Original languageEnglish
Title of host publicationContemporary Ergonomics and Human Factors 2016
EditorsPatrick Waterson, Ruth Sims, Ella-Mae Hubbard
Place of PublicationLoughborough UK
PublisherChartered Institute of Ergonomics & Human Factors
Pages95-99
Number of pages5
ISBN (Print)9780955422591
Publication statusPublished - 2016
EventInternational Conference on Contemporary Ergonomics and Human Factors of the Institute-of-Ergonomics-and-Human-Factors 2016 - Staverton Park, Daventry, United Kingdom
Duration: 19 Apr 201621 Apr 2016

Conference

ConferenceInternational Conference on Contemporary Ergonomics and Human Factors of the Institute-of-Ergonomics-and-Human-Factors 2016
CountryUnited Kingdom
CityDaventry
Period19/04/1621/04/16

Keywords

  • Bow-tie analysis, guidewire, patient safety, retained foreign object.

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