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Author James WARD, Maria Mikela CHATZIMICHAILIDOU, Tim HORBERRY, Yi-Chun TENG and John CLARKSON |
| Abstract Never events are typically rare but serious incidents in healthcare. They are perceived to be preventable, and include the retention of a surgical instrument in a patient's body. One such instrument is a "guidewire", which is used to help introduce a catheter tube into the venous system of a patient. Following a number of guidewire retentions, these authors investigated contributing factors and examined mechanisms to reduce the risk of further occurrences. This paper presents the results in the form of a bow-tie analysis, which was found to provide an effective way to graphically display and examine the issue. |
