Department numbers Hospital map Parking Visiting times
Home
News

 

The Venner WireSafe™

The Wiresafe™ is an engineered safety innovation designed to prevent the never event of retained guidewires.

Central lines are used in intensive care units and operating theatres to administer multiple or strong medications that cannot be administered peripherally, at times they are used to measure a patient's central venous pressure to assist with fluid management.

Awards:

  • Finalist, HSJ awards. Acute Sector Innovation (2018)
  • Presidents award for outstanding achievement, Royal College of Anaeshetists, SALG Patient Safety Conference (2016)
  • Finalist, highly commended, The National Patient Safety Award (2016)
  • Clinical Opinion

    "When you make an error like this, it stays with you and affects you in so many ways. You can't believe that you've been responsible for harming a patient and it makes you doubt yourself as a doctor. I'm glad that the solution has finally been developed."

    "I know of doctors who have forgotten to remove the guidewire. As far as I can see the WireSafe™ makes this error all but impossible, protecting both staff and patients."

    "I like the way that it turns intoa sharps box and allows easy cleaning up at the end. It actually makes the whole procedure easier for me."

    "I've used the WireSafeTM previously in a trial...had we been continuing to use the WireSafe™, I would have put all of the sharps inside the WireSafeTM, rather than carry them to the sharps bin. I'm sure I would not have had this injury if we were continuing to use the WireSafeTM." (Foundation training Doctor, following a sharps injury)

    Why the WireSafe™ was developed

    In order to insert a central line, a guidewire must be first inserted into the patient's vein, the catheter is then placed over it and the guidewire is then removed.

    If the clinician forgets to remove the guidewire, it can travel to the heart, causing devastating complications. This mistake has a mortality of up to 20% for patients. The mistake happens because the clinician is distracted at a critical point in the procedure. The vast majority of guidewires are simply forgotten by the clinician until hours, days or weeks later, when it is too late to easily remedy.

    When the error occurs, the patient must be transferred to be seen by an interventional radiologist or cardiac surgeon, and undergo an unnecessary procedure in order for the guidewire to be removed.

    A retained guidewire is a Never Event, and data from NHS England shows that this error occurs on average 1-2 times per month in the NHS. However, with an incidence of 1:3000 procedures, we know that this error is under-reported.,/p>

    Current solutions have suggested that clinicians should be more vigilant, should have two people performing the procedure, have a checklist and document guidewire removal. However, these solutions are costly to introduce and unreliable, because this error still occurs despite their introduction.

    Guidewires Unintentionally Retained During Central Venous Catheterisation. Journal of the Association for Vascular Access. (2014)

    NHS Improvement, Never Events Data. (Live)

    Preventing Retained Central Venous catheter guidewires: A Randomised Controlled Simulation Study Using a Human Factors Approach. Anaesthesiology. (2017)

    The WireSafe™ is an engineered solution designed to prevent this Never Event. Using human factors engineering, a forcing function has been designed into the procedure which prevents the clinician from completing the procedures unless they first remove the guidewire.

    WireSafe™ has a locking mechanism and contains the equipment required to complete the procedure after the guidewire has been removed: the stitch, needle holder, dressings.

    It is all but impossible to access the equipment without using the guidewire to unlock the box.

    This forcing function, at the crucial point in the procedure, ensures that the clinicians cannot continue with the procedure without first removing the guidewire.

    Once the guidewire has been used to access the equipment and the procedure is completed, the WireSafe™ converts into a sharps box, to dispose of all sharps used in the procedure. WireSafe™ can then be safely disposed of into the sharps bin.

    Guidewire retention - not a problem? European Journal of Anaesthesiology. (2015)

    1 2 3
    The WireSafe™ contains the contents required to complete a central lie insertion Open the WireSafe™ using the guidewire Dispose of the sharps inside the WireSafe™ and dispose in the sharps bin

    Procurement

    WireSafe™ can be produced from Qualitech Healthcare (UK) or Venner Medical

    Clinical Evidence

    The WireSafe™ was designed to prevent the error of retained guidewires.

    In a national survey, 33% of lead ICU clinicians have seen this error occur in their ICU. The NHS England report this error occurs 1-2 times per month.

    Read more about this

    The WireSafe™ is significantly better at preventing retained guidewires than standard practice alone (P>0.001).

    A simulation study was conducted to determine to risk of retained guidewires comparing staandard practice to the WireSafe™. Junior doctors were presented with a scenario where a colleague had been urgently called away mid-way through a central line procedure. Participants were required to safely complete the procedure and return the patient to the ward. The manikin model had a central venous catheter inserted in the right internal jugular vein, with the guidewire present in the distal lumen, clearly visible through the transparent portion of the lumen and retrievable with forceps if required. There was also an ECG monitor showing ectopic beats.

    In the standard group, 80% did not recognise the guidewire in situ, they completed the procedure and returned the patient to the ward. In the WireSafe™ group, participants did not immediately recognise the retained guidewire. They attempted to complete the procedure, however when unable to access the contents of the WireSafe™, it triggered the participants to search for the guidewire. Participants looked in the trolley, floor and sharps bin before recognising that it was inside the patient. All were able to retrieve the guidewire and complete the procedure without complications. The WireSafe™ prevented guidewire retention in all cases and was statistically superior in preventing guidewire retention compared with standard practice (P<0.001).

    Read more here:

    European Journal of Anaesthesiology, 2015; Volume 32, Supplement 53 16AP2-4

    Implementation

    In order to support the implementation of WireSafe™ the Oxford AHSN has produced and implementation booklet which will guide clinicians on how to introduce the innovation into their hospital

    WireSafe book

    Supported by:

    To return to the innovations page, click here.