Guidewire left in Situ (Never event) - June 2022

Learning Summary from Incident Reviews and Investigations

Category:	Treatment / procedure inappropriate / wrong
Speciality:	Critical (Intensive) Care (ITU)
When	June 2022
Reference	195517
Keywords	Guidewire (Never event)

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
Author: Lee Booker

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