Horberry Tim, Teng Yi-Chun, Ward James, Patil Vishal, Clarkson P John
Engineering Design Centre, Department of Engineering, University of Cambridge, Cambridge, UK Minerals Industry Safety and Health Centre, University of Queensland, Brisbane, Australia.
Engineering Design Centre, Department of Engineering, University of Cambridge, Cambridge, UK.
Int J Risk Saf Med. 2014;26(1):23-37. doi: 10.3233/JRS-140610.
Central Venous Catheterisation (CVC) has occasionally been associated with cases of retained guidewires in patients after surgery. In theory, this is a completely avoidable complication; however, as with any human procedure, operator error leading to guidewires being occasionally retained cannot be fully eliminated.
The work described here investigated the issue in an attempt to better understand it both from an operator and a systems perspective, and to ultimately recommend appropriate safe design solutions that reduce guidewire retention errors.
Nine distinct methods were used: observations of the procedure, a literature review, interviewing CVC end-users, task analysis construction, CVC procedural audits, two human reliability assessments, usability heuristics and a comprehensive solution survey with CVC end-users.
The three solutions that operators rated most highly, in terms of both practicality and effectiveness, were: making trainees better aware of the potential guidewire complications and strongly emphasising guidewire removal in CVC training, actively checking that the guidewire is present in the waste tray for disposal, and standardising purchase of central line sets so that differences that may affect chances of guidewire loss is minimised.
Further work to eliminate/engineer out the possibility of guidewires being retained is proposed.
中心静脉置管（CVC）术后偶尔会出现患者体内导丝残留的情况。理论上，这是一种完全可以避免的并发症；然而，与任何人为操作一样，导致导丝偶尔残留的操作者失误无法完全消除。
本文所述工作对该问题进行了研究，试图从操作者和系统角度更好地理解这一问题，并最终推荐适当的安全设计解决方案，以减少导丝残留错误。
采用了九种不同的方法：观察操作过程、文献综述、采访CVC终端用户、构建任务分析、进行CVC程序审核、两项人因可靠性评估、可用性启发式评估以及对CVC终端用户进行全面的解决方案调查。
就实用性和有效性而言，操作者评价最高的三种解决方案是：让实习生更好地了解导丝潜在并发症，并在CVC培训中大力强调导丝拔除；积极检查导丝是否在待处理的废物盘中；标准化中心静脉套件的采购，以尽量减少可能影响导丝丢失几率的差异。
建议进一步开展工作，消除/设计出消除导丝残留可能性的方法。
