The Sequelae of Silence: Catheter Entrapment as a Preventable Morbidity Resulting from Communication Failure
Keywords:
Central venous catheter; Central line, Catheter; Entrapment; Suture; Cardiothoracic, Cardiac surgery; Anesthesia; Stuck catheter; Stuck line, Safety; Interdisciplinary, Communication Swiss cheese, Morbidity ReoperationAbstract
Medical errors follow a well-established association with communication failure.
Seemingly benign interventions such as central venous catheterization can have far reaching
consequences. A 72-year-old male required reoperative mitral valve replacement surgery for
culture negative endocarditis. Intraoperatively, a central venous catheter was placed without
communication between the surgical and anesthesia teams. Despite a seemingly uneventful
operative and post-operative course, prior to discharge, the catheter was unable to be removed
and necessitated surgical removal. Bidirectional communication during cardiovascular surgery
is key to achieving optimum outcomes. Fortunately, it often requires many errors to lead to unnecessary
morbidity, however sometimes it takes but one.
