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OBJECTIVES:

Guidewire retention after intravascular catheter insertion is considered a “never event.” Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention.

DESIGN:

Pre-specified observational analysis as part of a quality improvement study of consecutive guidewire retention events across a multihospital health system from August 2007 to October 2015.

SETTING:

Ten hospitals within the Cleveland Clinic Health System in Ohio, United States.

PATIENTS:

Consecutive all-comers who experienced guidewire retention after vascular catheter insertion.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Data were manually …