Evaluating the ex post facto report system of central venous catheterization brought in our hospital three years ago as a device for its risk management

Abstract

In April 2009, for the purpose of risk management in central venous catheterization (CVC), the ex post facto report system was introduced in our hospital. An analysis of presented reports found that the annual total number of CVC has been significantly decreasing in three years and in addition that the proportions of selecting multi-lumen catheters and landmark-depending introduction of needles are trending downward. On the other hand it was revealed that over-three-time stub forbidden in our CVC manual has remained and that acquirement of informed consent in advance and maximum sterile barrier precaution cannot be executed perfectly. Together with continuing this report system, actions are needed such as repetitious induction of the manual, periodical workshop on safe maneuver and case conference when some accident in relation to CVC occurs.