Unintentionally retained guidewires: a descriptive study of 73 sentinel events.

Victoria M. Steelman; Kokila Thenuwara; Clarissa Shaw; Laurel Shine

Study

Unintentionally retained guidewires: a descriptive study of 73 sentinel events.

March 20, 2019

Steelman VM, Thenuwara K, Shaw C, et al. Jt Comm J Qual Saf. 2019;45(2):81-90.

View more articles from the same authors.

This retrospective review examines incidents of retained guidewires reported to The Joint Commission. Researchers identified numerous contributing factors to these events, most frequently relating to human factors, leadership, and communication. The authors conclude that multicomponent strategies to prevent incidents involving retained foreign objects are needed.

PubMed citation

Available at

Related Resources From the Same Author(s)

Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.

November 28, 2018

Accountability in nursing practice: why it is important for patient safety.

December 10, 2014

Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.

August 17, 2011

Top 10 patient safety issues: what more can we do?

June 19, 2013

Priority patient safety issues identified by perioperative nurses.

May 8, 2013

The hidden costs of reconciling surgical sponge counts.

November 11, 2015

Surgical specimen management: a descriptive study of 648 adverse events and near misses.

October 5, 2016

Patient safety strategies: a call for physician leadership.

March 13, 2013

Two decades since To Err Is Human: progress, but still a "chasm".

January 13, 2021

Patient safety and collaboration of the intensive care unit team.

April 22, 2009

In search of common ground in handoff documentation in an intensive care unit.

May 23, 2012

Evaluating situation awareness: an integrative review.

May 10, 2017

Preventing medical errors: how to proceed with caution.

September 10, 2014

Adverse events and near miss reporting in the NHS.

August 24, 2005

Finding blunders in thyroid testing: experience in newborns.

July 30, 2008

Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic review and narrative synthesis.

April 25, 2018

Quality improvement and safety in pediatric emergency medicine.

March 6, 2019

Developing a national patient safety education framework for Australia.

January 3, 2007

Judging whether a patient is actually improving: more pitfalls from the science of human perception.

June 6, 2012

Pediatric adverse drug events in the outpatient setting: an 11-year national analysis.

October 14, 2009

Adverse drug events in the outpatient setting: an 11-year national analysis.

July 28, 2010

Detection of patient risk by nurses: a theoretical framework.

February 17, 2010

Improving accuracy of handoff by implementing an electronic health record-generated tool: an improvement project in an academic neonatal intensive care unit.

October 21, 2020

Implementation, CPOE, and medication errors.

June 8, 2005

Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.

August 21, 2013

Inequities in quality and safety outcomes for hospitalized children with intellectual disability.

March 16, 2022

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

September 24, 2014

Individual surgeon mortality rates: can outliers be detected? A national utility analysis.

November 16, 2016

Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011.

May 4, 2016

Nurse reports of adverse events during sedation procedures at a pediatric hospital.

November 11, 2009

Do crowdsourced hospital ratings coincide with Hospital Compare measures of clinical and nonclinical quality?

September 12, 2018

Near miss audit in obstetrics.

May 2, 2007

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

January 27, 2021

Participation in EHR based simulation improves recognition of patient safety issues.

December 10, 2014

Opportunities for diagnostic improvement among pediatric hospital readmissions.

June 28, 2023

Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences.

April 3, 2019

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

July 20, 2011

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review.

June 1, 2016

Clinicians' perceptions of medication errors with opioids in cancer and palliative care services: a priority setting report.

May 30, 2018

Reported clinical incidents of children with intellectual disability: a qualitative analysis.

June 15, 2022

A practical approach to measure the quality of handwritten medication orders: a tool for improvement.

May 24, 2006

Safe prescribing: an educational intervention for medical students.

July 19, 2006

ASHP guidelines: minimum standard for ambulatory care pharmacy practice.

July 22, 2015

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies.

September 18, 2019

Medication reconciliation to facilitate transitions of care after hospitalization.

June 10, 2015

The Shift Coupon: an innovative method to monitor adverse events.

January 18, 2006

Community pharmacy medication review, death and re-admission after hospital discharge: a propensity score-matched cohort study.

September 4, 2019

Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions.

March 30, 2022

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs.

October 21, 2015

A review of verbal order policies in acute care hospitals.

January 18, 2012

PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors.

June 29, 2016

Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center.

April 9, 2014

Success of a resident-led safety council: a model for satisfying CLER Pathways to Excellence patient safety goals.

October 9, 2019

Pediatric patient safety in emergency departments: unit characteristics and staff perceptions.

August 19, 2009

Reported medication events in a paediatric emergency research network: sharing to improve patient safety.

November 28, 2012

Doctors' stress responses and poor communication performance in simulated bad-news consultations.

December 9, 2009

An integrative review: fatigue among nurses in acute care settings.

November 5, 2014

Reducing medication prescribing errors in a teaching hospital.

August 27, 2008

Hospitalized patients' attitudes about and participation in error prevention.

May 17, 2006

New solutions to reduce wrong route medication errors.

December 13, 2017

Exploring nurses' attitudes, skills, and beliefs of medication safety practices.

August 24, 2022

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

January 18, 2006

Radiologic safety events within a pediatric emergency medicine network.

June 7, 2017

Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety.

January 15, 2020

A simulation design for research evaluating safety innovations in anaesthesia.

January 28, 2009

Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network.

April 3, 2013

The Medication Manager: results of a medication at the bedside pilot in a pediatric teaching institution.

June 23, 2010

Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures.

September 2, 2015

Clinicians' perceptions of opioid error–contributing factors in inpatient palliative care services: a qualitative study.

May 22, 2019

Evaluation of patient and family outpatient complaints as a strategy to prioritize efforts to improve cancer care delivery.

October 4, 2017

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

October 16, 2019

Lessons learned from a systems approach to engaging patients and families in patient safety transformation.

February 12, 2020

Quality and safety practices among academic obstetrics and gynecology departments.

August 30, 2023

Quality improvement for patient safety: project-level versus program-level learning.

February 22, 2012

We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication.

March 19, 2014

Differences in safety report event types submitted by graduate medical education trainees compared with other healthcare team members.

December 8, 2021

Accountability for medical error: moving beyond blame to advocacy.

August 17, 2011

Hospitalized patients' participation and its impact on quality of care and patient safety.

January 30, 2005

Nurses' communication of safety events to nursing home residents and families.

November 15, 2017

Lost opportunities: how physicians communicate about medical errors.

January 23, 2008

Incident reporting to improve patient safety: the effects of process variance on pediatric patient safety in the emergency department.

August 1, 2018

Patient safety event reporting expectation: does it influence residents' attitudes and reporting behaviors?

June 5, 2013

Near misses and unsafe conditions reported in a Pediatric Emergency Research Network.

September 23, 2015

Good Practice Guides on Medication Errors: Part 1 and Part 2.

April 13, 2016

Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report.

November 1, 2023

How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care?

June 4, 2008

US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.

August 16, 2006

Associations between self-reported healthcare disruption due to COVID-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England.

August 9, 2023

Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: systematic review of qualitative evidence.

August 2, 2023

Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.

May 7, 2008

The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study.

October 9, 2013

Exploring error in team-based acute care scenarios: an observational study from the United Kingdom.

June 6, 2012

Understanding the behaviour of newly qualified doctors in acute care contexts.

November 2, 2011

Systematic review of clinical debriefing tools: attributes and evidence for use.

April 19, 2023

Correlation between hospital finances and quality and safety of patient care.

September 4, 2019

A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.

May 31, 2017

Patient safety event reporting in critical care: a study of three intensive care units.

March 21, 2007

Implementing a commercial rule base as a medication order safety net.

August 31, 2005

A human factors and survey methodology-based design of a web-based adverse event reporting system for families.

May 5, 2010

Patients' concerns about medical errors during hospitalization.

January 3, 2007

Related Resources

Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units.

April 17, 2024

Annual Perspective

Communication During Transitions of Care

March 27, 2024

Special Section: IEA Health Care 2021.

February 28, 2024

Application of "Human Factor Analysis and Classification System" (HFACS) model to the prevention of medical errors and adverse events: a systematic review.

February 7, 2024

WebM&M Cases

Misconnection Leading to Arterial Thrombosis

June 28, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

An examination of Leapfrog safety measures and Magnet designation.

April 5, 2023

Sources of nurse-sensitive inpatient safety improvement.

December 21, 2022

WebM&M Cases

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

September 28, 2022

Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update.

June 22, 2022

Annual Perspective

Annual Perspective: Psychological Safety of Healthcare Staff

March 31, 2022

Cost of health care-associated infections in the United States.

March 23, 2022

WebM&M Cases

Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care

November 30, 2021

Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0

January 29, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

Human factors considerations in using personal protective equipment in the COVID-19 pandemic context: a bi-national survey study.

July 1, 2020

WebM&M Cases

When the Indications for Drug Administration Blur

June 24, 2020

Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations.

June 24, 2020

What is an ethically informed approach to managing patient safety risk during discharge planning?

January 20, 2020

Patient Safety Primers

Patient Safety 101

September 7, 2019

The wicked problem of patient misidentification: how could the technological revolution help address patient safety?

May 1, 2019

Using incident reports to assess communication failures and patient outcomes.

April 17, 2019

Debriefing in the OR: a quality improvement project.

March 13, 2019

WebM&M Cases

Which Line: Ordering Provider or Proceduralist?

March 1, 2019

Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad.

February 6, 2019

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.

January 23, 2019

How communications issues between doctors and nurses can affect your health.

September 19, 2018

Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages.

June 13, 2018

Latex: a lingering and lurking safety risk.

April 4, 2018

See More About The Topic

Hospitals

Nurses

Health Care Executives and Administrators

Medicine

Nurse Care

Unintentionally retained guidewires: a descriptive study of 73 sentinel events.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Unintentionally retained guidewires: a descriptive study of 73 sentinel events.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site