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Surprise Wire

Jeffrey M. Pearl, MD; Nancy E. Donaldson RN, DNSc | August 21, 2005
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The Case

A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinical condition in the ED, he required intubation as well as placement of a right femoral central venous catheter (CVC). In the ICU, his nurse experienced some difficulty using his central line, but she was able to draw blood back from all three ports. Over the course of the next week, the patient's condition improved, allowing for successful extubation and transfer out of the ICU. On the day of transfer, the ICU nurse removed the patient’s femoral catheter but discovered the guidewire (used at the time of placement in the ED) still in the patient's femoral vein. The nurse removed the wire easily and without incident.

Later investigation revealed that the ED physician, who placed the central line, inadvertently left the guidewire in place and failed to account for the missing guidewire at the end of the procedure. Although the error increased risk for an infectious or thrombotic complication, removal of the catheter occurred prior to any adverse event, and the patient was unharmed.

The Commentary

As this case illustrates, CVC placement is a common life-saving intervention in acute care settings.(1) Yet, despite its frequency in practice, CVC placement, management, and removal processes represent problem-prone events and may pose life-threatening sequelae. On the surface, this case represents a straightforward example of “leaving something behind.” Deeper analysis, however, reveals that it is fundamentally about the need for improved teamwork, communication, and CVC-related safety education.

Specifically, this case highlights the need for explicit processes of care, especially for routine procedures that require a team to carefully work through a series of tasks and manage the necessary equipment. One would not expect individuals to perform such procedures without the necessary support systems to ensure success. This success is defined by sterile and technically sound methods and a collaborative environment with clear communication, while accounting for necessary safety checks along the way. Root cause analyses of sentinel events reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revealed that 65% derive from communication failures and 55% from a lack of orientation and training.(2) Evidence suggests that multidisciplinary education, both self-directed and delivered in a group setting, can decrease CVC-related adverse events such as catheter-related infections.(3,4)

To strengthen both interdisciplinary collaboration and an understanding of patient safety related to vascular access devices (VAD), we developed a web-based VAD safety courseware (UCSF Venous Access Interdisciplinary Education Projected US DHHS HRSA Grant #1 D51 HP 10004 01;see slideshow). Our experience suggests that the vision for and reality of interdisciplinary patient safety education are quite divergent. Vascular access processes of care are complex and, although routine, demand a high degree of competency and collaboration by a cadre of providers. Our vision was to engage nursing and medical trainees in learning a common knowledge base related to VAD safety and to consider how they could better work together to ensure patient safety. We were challenged to synthesize relevant literature—across a number of disciplines—and to frame and develop the courseware in language that was engaging and familiar to the different disciplines. With that in mind, physicians, nurses, and specialty technicians would receive regular training in the core concepts of venous access safety—the ABCs—as they are increasingly involved in inserting, using, managing, removing, and troubleshooting central lines. Unfortunately, rapidly embedding these concepts into academic curricula as a “thread” is a challenge; it requires the commitment of academic leadership (such as deans), as well as the “buy in” of department chairs, course directors, and faculty.

Our experience was telling, and we share it in hopes that the lessons will be relevant to others who embark on this important mission. When we met with academic stakeholders, we found that they were all committed in concept to our aim, but the real challenge was to identify the reachable and teachable moment(s) within the medical and nursing educational curriculum. Unfortunately, we quickly discovered the challenge in getting students from multiple disciplines (ie, medicine, nursing, pharmacy) into a common classroom because of the logistic realities of their silos of coursework. As a result, we shifted our attention to embedding a web-based version of our courseware into the credentialing infrastructure, introducing a new set of stakeholders, instructional design issues, and dissemination opportunities to our work. In other words, the realities of developing new multidisciplinary curricula within the academic milieu forced an easier path toward creating a scaleable, web-based curriculum and use of the credentialing/recredentialing process as an opportunity and lever to promote its use. We are fortunate to work in an institution that has an online educational system (the UCSF Training OnLine System), which provided the scaffolding to host our curriculum. This allowed us to reach not only trainees and newly minted clinicians but also more experienced clinicians.

One of the primary benefits of web-based courses is the ability for providers to participate in them at any time and from any computer with internet access. Our course allows users to acquire knowledge and also be evaluated prior to and upon competition of each learning session, all documented online. Based on input from clinician users, we refined and simplified our educational modules and added features to tailor the web-based material for specific learners. For example, users can drill down into the content (or not) based on their prior learning. However, managing the courseware, the web-based learning, and the ongoing technological issues requires dedicated expertise and resources. Ideally, institutions and campuses will develop the capacity for safety-focused multidisciplinary instructional technologies. It will simply not be feasible for investigators and teachers to independently develop and sustain the web-based infrastructure for every quality- or safety-focused project. Although our system at UCSF provides basic capacity, if we are to move into an era in which a series of web-based educational modules for trainees and practicing clinicians will be hosted, the infrastructure, level of support personnel, and ease of use will need to reach greater heights. In a large institution like ours, we have seen remarkable pockets of expertise and capacity in the library, medical center, and schools of nursing, medicine, and pharmacy. However, without integration into a new unit focused on campus-wide web-based education, they will not be sufficient. Creating a new “model” is a strategic and clinical imperative for our academic, clinical, and dissemination purposes.

In addition to educational efforts, our experience continues to suggest, and the literature affirms (5,6), that the ultimate impact on patient safety requires system commitment by operationalizing training documentation, including ongoing demonstration of competencies. Near-miss and actual adverse VAD-related clinical events, reported in the literature or experienced closer to home, have provided valuable insight into gaps in safety. These safety problems led to improved venous access policies, practices, systems, and competencies, all of which informed the development and targeted learning outcomes of our courseware. For example, we produced a mini-module on CVC removal to ensure all clinicians understood critical principles related to prevention of air emboli.(7) We discovered that the mere act of closely examining our practices and developing evidence-based courseware “raises the bar” for common procedures, such as femoral line placement, by catalyzing discussion and critique of current practice and refining it to optimize patient safety.

Clearly, clinicians require system-wide efforts to help “do it right”—we should no longer depend on individuals to ensure their ongoing knowledge and skills in safety and quality-related domains. Thus, coupled with our ongoing educational efforts, the new UCSF CVC Removal “Kit” (Figure) includes the air occlusive dressing, while a previous version required the clinician to acquire the dressing and the kit from the supply cart prior to the procedure, increasing the likelihood that a non-air occlusive dressing might be used. In the case presented, it is tempting to focus on the lack of training and the clinician who performed the procedure without addressing the underlying need for redundant safety systems. A better approach involves encouraging teamwork and coordinated patient safety efforts during this and every procedure. And, although controversial (8), consideration of a post-procedure x-ray requirement might provide another safety check to verify catheter positioning and ensure that nothing is left behind.

Take-Home Points

  • While routine, VAD clinical processes, especially those involving CVCs, are complex and problem-prone.
  • VAD safety training must be created with a multidisciplinary focus in mind. Utilization must be reflected in medical and nursing education curriculums with assurance of necessary competencies.
  • Implementing various safety curricula in large institutions requires attention not only to the content, but also to the method of delivery (seminars, lectures, web-based), and the practical and political realities of making the content available and encouraging or requiring that people take advantage of it.

Jeffrey M. Pearl, MD Associate Dean and Clinical Professor of Surgery University of California, San Francisco School of Medicine

Nancy E. Donaldson RN, DNSc Clinical Professor and Director UCSF Stanford Center for Research & Innovation in Patient Care University of California, San Francisco School of Nursing


1. O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR Recommendations and Reports [CDC Web site]. August 9, 2002;51:1-26. Available at:

2. National Patient Safety Goals for 2005 and 2004. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations.

3. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014-2020. [ go to PubMed ]

4. Warren DK, Zack JE, Mayfield JL, et al. The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest. 2004;126:1612-1618. [ go to PubMed ]

5. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

6. Rufener JB, Andrews RT, Pfister ME, et al. An evaluation of commonly employed central venous catheter kits and their potential risk for complications of excess guidewire introduction. J Clin Anesth. 2003;15:250-256. [ go to PubMed ]

7. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140:1025-1033. [ go to PubMed ]

8. Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol. 2003;14:527-534. [ go to PubMed ]


Figure. Central Venous Catheter (CVC) Removal “Kit”


Slideshow. Sample of the Venous Access Patient Safety course from the UCSF Training OnLine System.

View the slideshow as a pdf

Source: UCSF Venous Access Safety Series: Reducing Patient Safety Risks When Removing Central Venous Catheters © The Regents of the University of California 2004. All rights reserved April 15, 2004.
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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