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The human error: delayed diagnosis of intravascular loss of guidewires for central venous catheterization.

Research paper by Marion M Auweiler, Sandra S Kampe, Markus M Zähringer, Shariah S Buzello, Tilmann T von Spiegel, Walter W Buzello, Khosro K Hekmat

Indexed on: 22 Nov '05Published on: 22 Nov '05Published in: Journal of Clinical Anesthesia



Abstract

We report three recent cases in which there was intravascular loss of the entire guide wire. In one case, this loss was discovered more than three months after the patient's procedure. In another case, the loss was detected one month later, and in the third case, four days was the interval of the loss. We discuss the problems of human error and failure of diagnosis, both of which were responsible for serious sequelae.