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Ugeskrift for laeger · Oct 2005
Case Reports[Don't always rely on PACS: undetected loss of a central venous catheter guide wire].
- Jacob Huusom and Peter Lommer Kristensen.
- Hillerød Sygehus, Anaestesiologisk Afdeling.
- Ugeskr. Laeg. 2005 Oct 10;167(41):3891-2.
AbstractA 74-year-old woman had a CVC inserted. Unfortunately, the guide wire was lost under the procedure, and despite a chest X-ray control it was not detected. The reason the guide wire was not identified was insufficient fine-tuning of the >local< PC monitor. We recommend regular fine-tuning of monitors used for X-ray control.
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