Whole central venous catheter (CVC) guidewire retention is an iatrogenic error, with an incidence of 1:3,167, a morbidity of 4-53%, mortality of 4-6% and is a never event. Since 2011, health policy has mandated that all hospitals must implement national safety guidance to prevent this error, emphasising that the never event will be prevented if the guidance has been introduced. Despite this, the error continues to occur, and the reported frequency is rising. The aim of this thesis was to identify a novel approach to prevent this error occurring.

A literature search, an analysis of ten years of CVC guidewire retention events nationally, and interviews with ten clinicians who had made the error were conducted. Guidewire retention was found to be an omission error, occurring due to distraction or interruption at a ‘critical point’ in the CVC procedure. Current safety mechanisms were mostly ineffective, and none were 100% effective. Strategies were operator focused interventions and performed after the error had occurred when correction may be difficult. An intraprocedural systems solution that prevents over-insertion or forces early recognition was required. Several solutions were developed and trialled. Finally, the locked procedure pack was deemed the best solution, due to ease of use and implementation, and low cost.

A randomised controlled forced error simulation study was used to assess efficacy of the locked procedure pack and prevented CVC guidewire retention in 10/10 versus 2/10 with standard practice (p < 0.001). The locked procedure pack was developed into a clinical product and renamed ‘WireSafe’. When introduced into clinical practice, there were no demonstrable negatives compared to standard practice on procedure duration (10% noninferior margin, p = 0.44), with a significant improvement in sharps safety (100% WireSafe versus 47% standard practice, p = 0.0008) and wide staff acceptability of the device in terms of preventing guidewire retention and improving sharps safety (20/20). Finally, a novel ‘suck out’ suction technique was developed to aid guidewire retrieval. No difference in retrieval techniques were found when the guidewire was retained above skin level, however the ‘suck out’ technique was significantly better when the guidewire was retained below skin level in 9/10 versus 0/10 in withdrawal and 1/10 in clamp and withdrawal (p < 0.001).

The WireSafe prevents CVC guidewire retention, protects clinicians from making this error and protects patients from the morbidity and mortality associated with this error. Further work is still required to evaluate the effectiveness of the solution through large scale clinical studies.