Retained guidewires in the Veterans Health Administration: getting to the root of the problem.

Cherara L, Sculli GL, Paull DE, Mazzia L, Neily J, Mills PD. J Patient Saf. 2018 Feb 13; [Epub ahead of print].

This study examined reports stemming from retained guidewires, a never event, across Veterans Affairs hospitals. Common causes included inexperience, lack of checklists, and insufficient standardization. The authors recommend applying human factors approaches to prevent this adverse event.

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