Extract:
“Any suspected arterial misplacement should be immediately reported to the Patient Safety Department to clarify all authorities and instructions. One aspect of this process is the workflow. In our experience, misplaced catheters in arteries are a common example of a medical incident related to central venous catheter insertion. Other organ injuries (e.g., pneumothorax and mediastinal deviation) may have occurred along with misplacement, making the typical case algorithm ineffective. Nevertheless, the organization must take all necessary measures to prevent mechanical complications from becoming lethal. This requires improved organizational and operational flows.”
Reference:Tokumine J, Fujimaki K, Moriyama K, Yorozu T. Workflow for treating inadvertent arterial placement of the central venous catheter. J Geriatr Cardiol. 2024 Nov 28;21(11):1096-1098. doi: 10.26599/1671-5411.2024.11.006. PMID: 39734649; PMCID: PMC11672356.