Accidental removal of dialysis central venous catheters: 9-year experience and prevention strategies in a Japanese community hospital
Abstract Background Accidental removal of dialysis central venous catheters is a potentially life-threatening complication in hemodialysis patients. This study investigated the incidence, risk factors, and outcomes of accidental catheter removal in a community hospital setting. Methods We conducted...
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BMC
2025-06-01
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| Series: | Renal Replacement Therapy |
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| Online Access: | https://doi.org/10.1186/s41100-025-00640-9 |
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| author | Soki Urushibara Akemi Hara Hirose Nakamoto Haruhisa Ozawa Yuki Nemoto Shun Watanabe Ryo Ohata Takuto Sakai Toyoaki Sawano Akihiko Ozaki Tomohiro Kurokawa Masayuki Okazaki Yukiko Kouchi Yutaka Tamada Naoto Yoshida Tetsuya Tanimoto Fumito Yamabe Junpei Iizuka Toshio Takagi Motoshi Hattori Hiroshi Kawaguchi Hiroaki Shimmura |
| author_facet | Soki Urushibara Akemi Hara Hirose Nakamoto Haruhisa Ozawa Yuki Nemoto Shun Watanabe Ryo Ohata Takuto Sakai Toyoaki Sawano Akihiko Ozaki Tomohiro Kurokawa Masayuki Okazaki Yukiko Kouchi Yutaka Tamada Naoto Yoshida Tetsuya Tanimoto Fumito Yamabe Junpei Iizuka Toshio Takagi Motoshi Hattori Hiroshi Kawaguchi Hiroaki Shimmura |
| author_sort | Soki Urushibara |
| collection | DOAJ |
| description | Abstract Background Accidental removal of dialysis central venous catheters is a potentially life-threatening complication in hemodialysis patients. This study investigated the incidence, risk factors, and outcomes of accidental catheter removal in a community hospital setting. Methods We conducted a retrospective analysis of patients who received dialysis central venous catheter insertions at our community hospital in Fukushima, Japan, from January 2015 to December 2023. We evaluated catheter insertions and removals; reviewed patient characteristics, catheter specifications, and clinical outcomes; and assessed the effectiveness of safety protocols implemented during the study period. Results We identified 2456 catheter insertions and 40 removal events (1.6%) among 39 patients (median age 81 years, 51.4% female). Cognitive impairment was present in 75.0% of documented cases. The overall removal rate was 1.5%, with higher rates in non-cuffed catheters (1.7%) than cuffed catheters (1.0%). Insertion sites included internal jugular (62.2%), femoral (35.1%), and subclavian (2.7%). Three fatal cases occurred with femoral catheters between 2016 and 2017, all during nighttime. No fatalities occurred after implementing comprehensive safety measures in 2020. Conclusions In this community hospital, accidental catheter removal occurred at a rate of 1.5%, with potentially fatal outcomes particularly among patients with femoral catheters. Comprehensive safety measures effectively prevented fatal events, although non-fatal removals persisted. |
| format | Article |
| id | doaj-art-ee464e775d924ae3845940e9c8ca52e7 |
| institution | DOAJ |
| issn | 2059-1381 |
| language | English |
| publishDate | 2025-06-01 |
| publisher | BMC |
| record_format | Article |
| series | Renal Replacement Therapy |
| spelling | doaj-art-ee464e775d924ae3845940e9c8ca52e72025-08-20T03:22:57ZengBMCRenal Replacement Therapy2059-13812025-06-0111111010.1186/s41100-025-00640-9Accidental removal of dialysis central venous catheters: 9-year experience and prevention strategies in a Japanese community hospitalSoki Urushibara0Akemi Hara1Hirose Nakamoto2Haruhisa Ozawa3Yuki Nemoto4Shun Watanabe5Ryo Ohata6Takuto Sakai7Toyoaki Sawano8Akihiko Ozaki9Tomohiro Kurokawa10Masayuki Okazaki11Yukiko Kouchi12Yutaka Tamada13Naoto Yoshida14Tetsuya Tanimoto15Fumito Yamabe16Junpei Iizuka17Toshio Takagi18Motoshi Hattori19Hiroshi Kawaguchi20Hiroaki Shimmura21Department of Urology, Jyoban Hospital of Tokiwa FoundationClinical Research Center, Jyoban Hospital of Tokiwa FoundationDepartment of Medical Quality and Safety Management, Jyoban Hospital of Tokiwa FoundationDepartment of Urology, Jyoban Hospital of Tokiwa FoundationDepartment of Urology, Jyoban Hospital of Tokiwa FoundationDepartment of Urology, Jyoban Hospital of Tokiwa FoundationDepartment of Urology, Jyoban Hospital of Tokiwa FoundationClinical Training Center, Jyoban Hospital of Tokiwa FoundationDepartment of Surgery, Jyoban Hospital of Tokiwa FoundationClinical Research Center, Jyoban Hospital of Tokiwa FoundationDepartment of Surgery, Jyoban Hospital of Tokiwa FoundationDepartment of Nephrology, Jyoban Hospital of Tokiwa FoundationDepartment of Urology, Jyoban Hospital of Tokiwa FoundationDepartment of Medical Quality and Safety Management, Jyoban Hospital of Tokiwa FoundationDepartment of Urology, Jyoban Hospital of Tokiwa FoundationDepartment of Internal Medicine, Navitas Clinic KawasakiDepartment of Urology, Jyoban Hospital of Tokiwa FoundationDepartment of Urology, Tokyo Women’s Medical UniversityDepartment of Urology, Tokyo Women’s Medical UniversityDepartment of Nephrology, Jyoban Hospital of Tokiwa FoundationDepartment of Nephrology, Jyoban Hospital of Tokiwa FoundationDepartment of Urology, Jyoban Hospital of Tokiwa FoundationAbstract Background Accidental removal of dialysis central venous catheters is a potentially life-threatening complication in hemodialysis patients. This study investigated the incidence, risk factors, and outcomes of accidental catheter removal in a community hospital setting. Methods We conducted a retrospective analysis of patients who received dialysis central venous catheter insertions at our community hospital in Fukushima, Japan, from January 2015 to December 2023. We evaluated catheter insertions and removals; reviewed patient characteristics, catheter specifications, and clinical outcomes; and assessed the effectiveness of safety protocols implemented during the study period. Results We identified 2456 catheter insertions and 40 removal events (1.6%) among 39 patients (median age 81 years, 51.4% female). Cognitive impairment was present in 75.0% of documented cases. The overall removal rate was 1.5%, with higher rates in non-cuffed catheters (1.7%) than cuffed catheters (1.0%). Insertion sites included internal jugular (62.2%), femoral (35.1%), and subclavian (2.7%). Three fatal cases occurred with femoral catheters between 2016 and 2017, all during nighttime. No fatalities occurred after implementing comprehensive safety measures in 2020. Conclusions In this community hospital, accidental catheter removal occurred at a rate of 1.5%, with potentially fatal outcomes particularly among patients with femoral catheters. Comprehensive safety measures effectively prevented fatal events, although non-fatal removals persisted.https://doi.org/10.1186/s41100-025-00640-9CatheterizationCentral venousRenal dialysisPatient safetyDevice removalCognitive dysfunction |
| spellingShingle | Soki Urushibara Akemi Hara Hirose Nakamoto Haruhisa Ozawa Yuki Nemoto Shun Watanabe Ryo Ohata Takuto Sakai Toyoaki Sawano Akihiko Ozaki Tomohiro Kurokawa Masayuki Okazaki Yukiko Kouchi Yutaka Tamada Naoto Yoshida Tetsuya Tanimoto Fumito Yamabe Junpei Iizuka Toshio Takagi Motoshi Hattori Hiroshi Kawaguchi Hiroaki Shimmura Accidental removal of dialysis central venous catheters: 9-year experience and prevention strategies in a Japanese community hospital Renal Replacement Therapy Catheterization Central venous Renal dialysis Patient safety Device removal Cognitive dysfunction |
| title | Accidental removal of dialysis central venous catheters: 9-year experience and prevention strategies in a Japanese community hospital |
| title_full | Accidental removal of dialysis central venous catheters: 9-year experience and prevention strategies in a Japanese community hospital |
| title_fullStr | Accidental removal of dialysis central venous catheters: 9-year experience and prevention strategies in a Japanese community hospital |
| title_full_unstemmed | Accidental removal of dialysis central venous catheters: 9-year experience and prevention strategies in a Japanese community hospital |
| title_short | Accidental removal of dialysis central venous catheters: 9-year experience and prevention strategies in a Japanese community hospital |
| title_sort | accidental removal of dialysis central venous catheters 9 year experience and prevention strategies in a japanese community hospital |
| topic | Catheterization Central venous Renal dialysis Patient safety Device removal Cognitive dysfunction |
| url | https://doi.org/10.1186/s41100-025-00640-9 |
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