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

J Clin Anesth. 2005 Nov;17(7):562-4. doi: 10.1016/j.jclinane.2004.11.007.

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.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Aged, 80 and over
  • Catheterization, Central Venous / adverse effects*
  • Catheterization, Central Venous / instrumentation
  • Coronary Artery Bypass
  • Female
  • Foreign Bodies / diagnostic imaging
  • Gastrointestinal Hemorrhage / etiology
  • Heart Valve Prosthesis Implantation
  • Humans
  • Jugular Veins
  • Male
  • Medical Errors*
  • Middle Aged
  • Radiography
  • Sepsis / complications