Patient Safety: Lessons Learned

Multiple factors lead to retention of guidewires

By: Alexis V. Reeves, RN CPHRM CLNC, Director of Patient Safety Operations & Transformation

Retention of guidewires occurs when a guidewire is used to insert various types of central lines. Central lines can be used to deliver caustic medications to high-volume fluids. They are typically used in very ill patients or in patients whose veins cannot accommodate a simple intravenous line.

In early 2014, Stanford Hospital was experiencing a spike in the retention of guidewires. In most of these instances, the central lines were being inserted under emergent situations in patients with rapidly deteriorating health. In such scenarios, physicians are focused on saving the patient's life, and the situation can put high levels of pressure on the care team. There is also an array of central line insertion kits available to the physician, which when coupled with the emergent nature of the situation, can be confusing.

Recognizing that there was a problem with the system, Stanford's Patient Safety Department performed a Failure Mode Effects Analysis (FMEA). This is a method for mapping out a current process, identifying the failures within each step of the process and then creating new, optimal processes. A group of physicians and nurses embarked on this analysis process, with assistance from the Patient Safety Department.

Their analysis uncovered a number of failures in the central line insertion process:

• Emergent insertion of central lines
• Non-standardized central line kits
• Non-standardized education on insertion of the central line
• Use of various techniques for line insertion
• Lack of situational awareness
• Lack of assistance for the physicians during the insertion of central lines

While the emergent nature of central line insertion cannot be prevented, the team quickly discovered that all of the other failure areas were fixable. After months of studying the problem and hours of literature research and discussions, the team developed a plan to standardize central line kits, developed standard education and obtained agreements from nursing to assist physicians in central line insertions.

Did this long and time consuming process help? The answer is yes! Thanks to a group of dedicated Stanford physicians and nurses, the last retained guidewire occurred on November 8, 2014.

To sustain the success of new central line insertion procedures, and to continue to prevent retention of guidewires, the Patient Safety department launched the "Don't let it go!" awareness campaign in February 2016.