Departure From Central Line Ritual
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alcohol and cocaine abuse was found unconscious by his neighbors. The patient had last been seen 2 days prior and complained of dizziness, thirst, and nausea. Emergency medical services found him unresponsive, with a Glasgow Coma Scale score of 3. He was intubated in the field. Upon arrival in the emergency department (ED), his pH was less than 6.8, carbon dioxide 37 mm Hg, oxygen 80 mm Hg, potassium 7.8 mEq/L, glucose 1400 mg/dL, lactate 11.2 mg/dL, and anion gap 42 mEq/L.
A right internal jugular line was placed for access. The resident who placed the line was relatively experienced in line placement but was unable to confirm placement with ultrasound. Instead he used manometry, which was not a part of the normal ED routine for line placement. He ultimately chose to pull the line. Just then, another trauma patient arrived, and the supervising attending physician left the room. The resident opened a second line insertion kit and restarted the process. Ultrasound was used to confirm correct placement. Upon flushing the line, it was noted that one of the ports was not working. The patient soon went into atrial tachycardia, which broke with adenosine. A chest radiograph was not obtained until later, after the patient went into ventricular fibrillation in the intensive care unit.
When the chest radiograph was finally completed, a retained wire was noted in the pulmonary artery. The interventional radiology team was consulted for wire removal. The retained wire likely caused a cardiac arrest, which required shocks, chest compressions, and cooling. After guidewire removal, the patient had no further episodes of arrhythmias, but experienced several other serious complications during a prolonged and stormy hospitalization.
This case represents a preventable medical error. In fact, this particular error—retained guidewire after central venous catheterization (CVC)—is so preventable that it has been characterized in the literature as "completely avoidable" and a "never event."(1,2) Nevertheless, this error continues to occur in numerous hospitals annually with a relatively constant event rate of 0.04 to 0.08 reported events per 1000 staffed hospital beds.(3) In order to successfully address this issue, we must systematically examine the root causes and focus proposed solutions on both error prevention and risk mitigation though early error recognition.
One could select a number of constructs to examine the specific situational components surrounding the root causes, and we choose to borrow from the injury prevention literature. The Haddon Matrix helped change the way that policymakers thought about injury prevention, in particular motor vehicle collisions.(4) Haddon defined three distinct phases of an injury event (pre-event, event, post-event) and the contributing agents of each phase (personal attribute, vector, etc.). In doing so, his matrix helped us realize that seatbelts and airbags are, in aggregate, far more beneficial than any post-event trauma surgical interventions.(5)
More recently and under different labels, the same principles have been applied to preventable medical errors. Let's use the Haddon structure to examine these specific interventions for CVC—a common procedure (more than 6 million done in the United States annually) with rare, but real complications (Table).(6-8) Some of these—such as pneumothorax and bleeding complications, are not always completely avoidable—others, like guidewire retention, should be.
The historic approach to preventing procedural errors in the emergency department (ED) has been based on experience (see one, do one, teach one) and dogma (in the case of CVC: "never let go of the tip of the guidewire once it is inserted"), which are clearly imperfect prevention tools. It is telling that this case provides no information on this emergency department's approach to pre-injury prevention. Did the department have a standardized approach to CVC? Did they have a protocol or policy in place? Here, the safety culture of the operating room (OR) provides us some ideas. Procedural checklists, inventory lists and review, and time outs all help prevent errors in the operating room. However, even in the operative setting, guidewire retention is not a never event.(9) The literature also recommends stocking and using a single CVC kit with safety features (such as color-coded guidewires), so that physician and staff do not make errors based on lack of familiarity and are provided clear safety cues.(1,3) As with procedural sedation in the ED, mandating a two-person procedural team approach to CVC would guarantee additional eyes watching each procedure.(10) With interdisciplinary team simulation training, these extra eyes may safely be borrowed from the nursing staff—assuming that a culture of psychological safety exists so that nurses are empowered to speak up and identify errors or deviation in protocol.(11,12)
As is frequently the case with medical errors, unexpected events during the procedure itself contributed to this error. The proceduralist opened a second kit, making it more difficult to assess for and recognize missing CVC kit components. In addition, as often occurs in the ED, another critical patient pulled the attending (planned to be the second operator) from the bedside. As documented in prior case series literature, inattention, inexperience, and inadequate supervision all resulted from the situational change. We can assume that these human factors also prevented the operator from following established best procedural practices, such as not advancing the wire past 18 to 20 cm and always maintaining a grip on the end of the wire.(13) These same error-permissive human factors were certainly still present when the proceduralist noted that they were not able to flush from a single port. Here, a clear opportunity for intra-event error recognition was lost. A second team member—and this need not be a physician—might have helped recognize the implication of the non-flushing port and caught the error in the event phase. Or, had the proceduralist team used a systematic counting procedure—as is routinely done in the OR—both during and after the procedure, they likely would have recognized that they were one wire short of a full two kits.(9)
In the case of CVC guidewire retention, post-event interventions center on early recognition. With early recognition, wires can normally be safely removed—usually via interventional radiology techniques—with minimal adverse effects. However, even in these simple cases, there is an efficiency cost, as well as a potential morbidity, inherent in any procedure. In some cases retained guidewires result in severe complications—with an incidence of moderate to severe harm of approximately 33%–38%.(10,13) In this case, the proceduralist deviated from standard procedure of obtaining a chest radiograph immediately after CVC. If such a study had been done in a timely fashion, it is likely that the patient would not have experienced the secondary complication of cardiac arrest in the intensive care unit.
While the resident in this case did verify appropriate placement of the catheter via ultrasound, as with the immediate verification of proper placement of an endotracheal tube, multiple modalities and techniques should be employed to confirm proper catheter placement.(3) Here again, checklists, immediate kit inventory assessment and two-person procedural teams could help identify the error early and/or make certain a chest radiography was obtained in a timely fashion.(3) Procedural-associated order sets—electronic or otherwise—might help facilitate by allowing for rapid omission-free ordering of procedural-associated tests as well as making documentation of guidewire removal a simple checkbox item.(9)
This case illustrates numerous opportunities to avert a completely avoidable medical error. An analysis of 30 cases of retained CVC guidewire identified communication, training, and policies as the most common root causes. These root causes have sufficient overlap with those expressed by end-users (the proceduralists themselves) in qualitative studies and provide us a rather clear set of take-home points.(10,14,15)
- Plan and train as teams to prevent complications and never events and do so through the entire pre-event to post-event continuum. The more staff members are aware of a potential complication, the greater the chances of its prevention.
- Implement at least one standardized policy or protocol to accompany emergency department CVC insertion: a checklist and/or an order set with assistive documentation features.
- Design trainings and policies to account for the unpredictable nature of ED flow and acuity. In a busy ED, a CVC policy that does not require the presence of two physicians is an invitation for periodic noncompliance.
- Promote added safety features into CVC designs that both offer visual prompts (colored guidewires) or advanced safety mechanisms (wire engagement only allows for one-way removal).
Dustin W. Ballard, MD, MBE Emergency Medicine Kaiser Permanente San Rafael, CA
David R. Vinson, MD Emergency Medicine Kaiser Permanente Sacramento, CA
Dustin G. Mark, MD Emergency Medicine Kaiser Permanente Oakland, CA
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Table. Haddon Matrix Applied to Retained Central Venous Catheter Guidewire.