[Don't always rely on PACS: undetected loss of a central venous catheter guide wire]

Abstract

A 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.