Abstract
Electrocardiographic (ECG) tip confirmation is a validated technique to place the distal tip of a peripherally inserted central catheter (PICC) in the distal superior vena cava at or near the cavoatrial junction during point-of-care insertions. This case report discusses an inadvertent arterial PICC placement despite navigation technology demonstrating similar confirmatory ECG changes seen in standard venous insertions. The findings demonstrate that ECG navigation technology should not be used to rule out arterial PICC placement.