Retained guidewires in central venous catheterisation: An analysis of omission errors

Complete intravascular loss of guidewires in patients is an on-going medical concern. This research investigates the guidewire insertion and removal procedure by using a common omission error model by James Reason to identify procedural disposition to omission errors. The research builds on a previous Hierarchical Task Analysis for central venous catheterisation and identifies two crucial points that need further examination with regard to guidewire loss. Suggestions for improved equipment, procedural and system design at these two task steps are given