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Safety Newsflash! Retained Guidewires.

17 Sep, 17 | by cgray

guidewires

If you’re a member of the Royal College of Emergency Medicine in the UK, you may have noticed an email pop up in your inbox recently, a safety newsflash on retained guidewires. RCEM put these out every few months, containing helpful and brief information in the crusade against events that should never happen, as well as some things to look out for when seeing patients. Examples of previous newsflashes include a reminder to think about AAA in patients with abdominal pain, and to remember that some oral dentures don’t show up on X-ray.

In this most recent installment, RCEM look at retained guidewires, which comes under number three on the NHS England list of never events – “retained foreign object post-procedure”. You might not think it’s common, and you’d be right – this has only happened eight times in emergency departments across the UK in the last two years, but that’s still eight too many. It makes up half of the reported never events in EDs.

With more and more emergency physicians utilising advanced skills to insert lines and chest drains in the resus room, it becomes so important to make sure we’re not causing patients harm through additional procedures to remove wires we’ve left behind.

So how do we do this?

RCEM’s advice follows that of the National Reporting and Learning System (NRLS), a branch of the National Patient Safety Agency. The aim is to make line insertion a standardised two-person task. Generally you can just put a line or drain in on your own, but having a second person as an observer, to witness and document guidewire removal, creates redundancy, with the aim of improving safety and focus on the task at hand

The NRLS advocate three measures to stop guidewires being left behind. The first is a standardised process where both the operator and observer see the guidewire removed, say it’s been removed, and document its removal. This may just be done in the notes, but I have seen in a trust I’ve worked in a sticker that comes pre-packaged in all arterial and central line kits with tickboxes and space to sign to standardise the documentation as well. It works very well, and putting it in the line packs makes it easy to remember to get an observer and complete the sticker to insert into the notes. This documentation is also audited.

The second measure is to emphasis guidewire control through training and education. We need to embed this as a mandatory step in all our lines or drains, just as we always clean the skin, or apply a dressing. It’s an important step, and should be emphasised not only to trainees being signed off to insert lines, but also to more senior doctors who have been putting them in for years.

Lastly, the NRLS is working with manufacturers to develop new ways to prevent guidewire retention.

RCEM has taken this and advocated a standardised procedural checklist for all invasive procedures. You can see this below.

 

invasive procedure checklist

 

Guidewire control is crucial, and if you’re not inserting these on a regular basis it can be all too easy to lose that control and lose your guidewire. Make sure you take steps to avoid this never event. Get an observer. Use the RCEM checklist, or your own trust one. Be safe for your patients.

vb

Chris

 

Don’t forget to check out the other safety newsflashes on the RCEM website.

Choosing Well vs. Choosing Wisely

10 Mar, 14 | by rradecki

In the United Kingdom, the NHS and Manchester publish “Choose Well” – a guide for patients in need, to help them find the healthcare resources correct for them.  The resources described include self-care, local general practitioner services, and advice regarding when to choose Urgent Care or Accident & Emergency services.  In a system where resources are Screenshot 2014-03-10 18.19.29understood to be finite, in order for all to have access to a reasonable level of healthcare, this is a prudent consumer-oriented approach.

The United States has a similarly-named system of choice – “Choosing Wisely”.  Published by the American Board of Internal Medicine Foundation, this initiative also focuses on making choices in healthcare.  However, rather than focusing primarily on helping patients make better choices, the true target of this initiative is an entirely different problem beguiling U.S. healthcare:  physicians behaving badly.  Screenshot 2014-03-10 18.19.49These initial lists, containing 5 or more items each, describe diagnostic tests and treatment modalities that ought to be re-examined – essentially, low-value candidates for expensive, harmful overuse that go further towards fattening physician and executive wallets, while providing uncertain patient-oriented benefit.

For Emergency Medicine in the U.S., the published list is prudent medicine – but hardly reflects the most costly & wasteful utilization of resources.  Several prominent academics and educators have critiqued this list informally, while others have systematically attempted to derive their own.  The important independent recommendations range from decreasing CT utilization, to mitigating over testing of low-risk chest pain, to avoiding costly hemostatic medications without clear indications.

Regardless, the point of distinction is clear – Choosing Well vs. Choosing Wisely.  Patients ought to be expected to benefit from educational programs to help improve their decision-making.  Physicians ought to be making high-value decisions every day – and we should be embarrassed our choices are so poor at baseline that an initiative such as Choosing Wisely even exists.

vb

Ryan Radecki

@emlitofnote

Ryan Radecki

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