As part of its efforts to improve the quality of health care delivery, the National Quality Forum (NQF) introduced the concept of “never” events. By deputizing the adverb never for an adjective in this context, NQF implies that it should be a reasonable expectation on the part of patients, payors, and the lay public that these events will not happen during the course of health care delivery. If only that were actually the case.1 Some of these never events—including wrong-site surgery and procedures (such as regional blocks and interventional pain procedures), death from venous air embolism in a health care setting, and retained foreign objects—can sometimes be attributed to the care delivered by anesthesiologists. Even though these events are rare, when they occur they may produce devastating morbidity or fatality; thus each one will require a root cause analysis to identify and fix any underlying system failure or failure of a fundamental safety mechanism that may have allowed such an event to occur.
We in anesthesiology are no different from our colleagues in other medical specialties: we dislike discussing our role in never events. Although never events are reported to accrediting bodies as sentinel events, these issues are infrequently discussed in the scientific journals of our specialty. In many ways, our culture in health care and concerns about liability claims and reports to the National Practitioner Databank encourage secrecy and discourage open and honest discussion of these events, with the goal of finding solutions and improving safety for future patients.
In this issue, Vannucci and colleagues2 from Washington University report a case series of retained guidewires after central venous line placements. We congratulate them for openly discussing these misadventures and for suggesting potential solutions to one type of serious adverse event, the avoidance of which is directly under our control. The authors point out that the incidence of retained guidewires is relatively common, and increasing.
How does this complication occur? Why would its incidence be increasing? Although the authors opine that operator factors such as fatigue, inexperience, or lack of education or training and clinical factors such as complex or unstable patients are the underlying cause, we disagree. We have seen separate cases in which a staff interventional radiologist and a staff specialist in pulmonary and critical care medicine had retained guidewires after procedures in stable patients. Surely these physicians could not be said to lack experience or education. We have seen a trainee have a retained guidewire 2 weeks before completing his residency. We have even seen one physician experience a second retained guidewire less than a year after having his first retained guidewire (with the attendant embarrassment and discussions with risk management staff). Vannucci and colleagues attempted additional education and simulation training, but observed no reduction in the incidence of retained guidewires. To those of us who have been down this road before, this is not a surprising result. Would anyone expect simulation training of surgeons, in and of itself, to be an effective way to reduce the incidence of retained items in abdominal wounds? We suspect that a lack of systems-based approaches to preventing this complication is to blame. Instead of engaging in systems-based thinking to prevent these never events, the medical community has usually preferred punitive approaches, including a “Soviet style” re-education or retraining of those who are actually (with their patients) “victims” of inadequately designed systems. While education and training, whether in a clinical setting or in a simulator, are essential to learning the Seldinger catheter-over-guidewire technique, such education and training will never prevent this complication from occurring while we continue to use the devices and kits that are currently available. Therefore, systems engineers and human factors experts are needed to re-engineer the central line process to prevent retention of guidewires, regardless of operator or patient settings.
In automobile safety, an example of a systems-based approach to solving a dangerous situation is the automatic transmission safety shift interlock. In modern vehicles built to today’s standards, it is not possible to start a car with the shifter set to “drive” or to shift a car out of “park” and into “reverse” without applying the brakes. Because of the problem of cars rolling on unlevel surfaces and potentially causing harm when unintentionally shifted out of park, the United States Department of Transportation issued Standard No. 102, mandating a safety system to prevent the problem from occurring. As reliable as the human brain is for memory, human error can and will still occur if not for intelligently designed safety systems. In the previous example it seems irrational to suggest that driver training courses would prevent drivers from shifting into reverse without a foot on the brake, so why do we think the same approach will work in medicine?
As noted earlier, it is not surprising that additional cases of retained guidewires occurred after mandatory training implemented at the authors’ institution. All training in skill-based activities has diminishing retention over time, and if there is any positive effect of the training it will be short lived. If the system flaw is not fixed, human factors engineers would say that the error will inevitably recur once the effect of training has worn off.
In our institution, we experienced 4 wrong-side preoperative regional anesthesia procedures (2 shoulder blocks, 2 lower-leg blocks). Since there was a relatively small group of faculty and residents on our acute pain service involved, we incorrectly assumed that education and training would prevent the recurrence of these events. After yet another wrong-side procedure, we redesigned the workflow for preoperative procedures including the performance of a more formalized preprocedure time-out, site marking for the location of the procedure, and most important, the presence of an independent and disinterested observer, such as a holding room nurse, to confirm the correct side for the procedure.3 The observer must be present before the start of the procedure and whenever there is any position change during the procedure, such as from supine to prone when confusion regarding laterality can occur. Without the presence of the individual, the procedure cannot be performed. Although the preventative procedures have only been in place for a short time, we have not had any additional mishaps.
Vannucci and colleagues correctly report that well-intentioned strategies aimed at this occurrence such as electronic record prompts and documentation of wire counts at best will only facilitate detection of the problem after it has occurred. We as a specialty need to embrace techniques grounded in the science of safety systems that are focused on prevention. Perhaps instead of counting guidewires at the end of a procedure to ensure they are all accounted for, we could design a process so that only one wire can be on the sterile field at a time. Alternatively, we could design better safety systems requiring attachment of a device to the external wire tip as the central line catheter is passed over the wire, obligating the operator to remove the wire at the end of the procedure. Only after we adopt systems approaches to counter the failure modes present in many of the high-risk activities in anesthesiology will we begin to move these sentinel events into the “never” category.
Name: Jeffrey Green, MD.
Contribution: This author helped write the manuscript.
Attestation: Jeffrey Green approved the final manuscript.
Name: John Butterworth, MD.
Contribution: This author helped write the manuscript.
Attestation: John Butterworth approved the final manuscript.
This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).
a Agency for Healthcare Quality and Research Patient Safety Network. Available at http://www.psnet.ahrq.gov/primer.aspx?primerID=3. Accessed April 12, 2012.
b United States Department of Transportation, Federal Motor Carrier Safety Administration. Standard No. 102. Available at http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.aspx?reg=571.102. Accessed April 12, 2012.
1. Neily J, Mills PD, Eldridge N, Carney BT, Pfeffer D, Turner JR, Young-Xu Y, Gunnar W, Bagian JP. Incorrect surgical procedures within and outside of the operating room: a follow-up report. Arch Surg. 2011;146:1235–9
2. Vannucci A, Jeffcoat A, Ifune C, Salinas C, Duncan JR, Wall M. Retained guidewires after intraoperative placement of central venous catheters. Anesth Analg. 2013;117:101–7
3. Rupp SM. Unintentional wrong-sided peripheral nerve block. Reg Anesth Pain Med. 2008;33:95–7