Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. | AHRQ Patient Safety Network

Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. | AHRQ Patient Safety Network

• Commentary
 
• Published March 2019

Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature.

Thonon H, Espeel F, Frederic F, Thys F. Acta Clin Belg. 2019 Mar 30; [Epub ahead of print].

The Swiss cheese model illustrates how independent weaknesses can combine to result in failure. This commentary examines factors that contribute to central venous catheterization mistakes and applies the Fishbone diagram to show areas requiring process improvement. The authors suggest steps before, during, and after central venous catheter placement to support safe practice.

PubMed citationAvailable at

Related Resources

JOURNAL ARTICLE › STUDY

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.

Saint S, Greene MT, Fowler KE, et al. BMJ Qual Saf. 2019 Apr 23; [Epub ahead of print].

JOURNAL ARTICLE › STUDY

Unintentionally retained guidewires: a descriptive study of 73 sentinel events.

Steelman VM, Thenuwara K, Shaw C, Shine L. Jt Comm J Qual Patient Saf. 2019;45:81-90.

PRESS RELEASE/ANNOUNCEMENT

ISMP Survey on IV Push Medication Practices.

Institute for Safe Medication Practices.

JOURNAL ARTICLE › STUDY

Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement.

Calderwood MS, Kawai AT, Jin R, Lee GM. Infect Control Hosp Epidemiol. 2018;39:897-901.

NEWSPAPER/MAGAZINE ARTICLE

Latex: a lingering and lurking safety risk.

Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.

View More