Guidewire left in Situ (Never event) - June 2022

Learning Summary from Incident Reviews and Investigations

Incident Summary

The multi-disciplinary team took swift action to prepare a deteriorating patient for theatre

There were many factors identified, the team worked to stabilise the patient who had a good outcome 

Our investigation found learning points for sharing across clinical teams.

Summary of findings

Communication: 

• The safety checklist including verbal confirmation of guidewire removal must be completed by the team placing medical devices at the time of procedure.
• before handover, there should be a pause between clinical procedures to provide an accurate situational report and a structured handover of care to ensure full information is given 

Imaging:

• Referrals to radiology to check placement of devices must include sufficient information regarding the number of devices in situ
• Additional equipment, such as monitoring wires, should be moved outside of the field of view on the chest x-rays to increase visibility of medical devices which require placement check.

Article ID: 296
Created: March 7, 2023
Last Updated: April 25, 2024

Online URL: https://elearning.cornwall.nhs.uk/site/kb/article.php?id=296