Assessment of the implementation of a national patient safety alert to reduce wrong site surgery

Rhodes, Penny; Giles, Sally; Cook, Gary; Grange, Angela; Hayton, R; Maxwell, Melanie; Sheldon, Trevor; Wright, John

doi:10.1136/qshc.2007.023010

Cited by 30 publications

(22 citation statements)

References 19 publications

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“…15,16 In the NHS the impact of other NPSA safety alerts has been inconsistent. 17,18 The reasons for alerts and guidelines not being adopted are complex. They involve professional norms and individual attitudes and behaviours as well as wider systems factors.…”

Section: Possible Solutionsmentioning

confidence: 99%

Patient safety matters: reducing the risks of nasogastric tubes

Yardley¹,

Donaldson²

2010

Clinical Medicine

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-Nasogastric tube insertion is a common clinical procedure carried out by doctors and nurses in NHS hospitals daily. For the last 30 years, there have been reports in the medical literature of deaths and other harm resulting from misplaced nasogastric tubes, most commonly associated with feed entering the pulmonary system. In 2005 the National Patient Safety Agency in England assembled reports of 11 deaths and one incident of serious harm from wrong insertion of nasogastric tubes over a two-year period. The agency issued a safety alert setting out evidence-based practice for checking tube placement. In the two and a half years following this alert the problem persisted with a further five deaths and six instances of serious harm due to nasogastric tube misplacement. This is a potentially preventable error but safety alerts advocating best practice do not appear to reliably reduce risk. Alternative solutions, such as standardising procedures, may be more effective.KEY WORDS: nasogastric tube, patient safety, safety alert IntroductionPhysicians have been intubating the gastrointestinal tract to allow artificial feeding since ancient times. 1 Today over 275,000 nasogastric tubes are supplied to the NHS annually (personal communication, NHS Supply Chain, May 2009). As with most medical procedures, there are risks to the use of these tubes. Some complications (eg epistaxis) are common and minor, others (eg oesophageal perforation and pneumothorax) are rare but serious.In recent years patient safety has emerged as a major issue of concern to healthcare providers. 2 Various approaches to improving safety have been used, including attempts to apply the experience of safety experts from other industries to hospital care. Over time, understanding of what approaches have most impact on reducing medical errors has grown. In this paper, the nature and scale of the problem of nasogastric tubes in England is reviewed. The limited impact of a safety alert is highlighted and the issue of nasogastric tube safety is used to illustrate other approaches to improving patient safety. Problems of nasogastric tubes in the NHSIn April 2004, an inquest was held into the unexpected death of an eight-year-old girl in an NHS hospital in England. She had required intubation and ventilation due to respiratory failure and was temporarily unable to eat or drink. A nasogastric tube was passed to administer enteral feed. The position of the tube was checked with the whoosh test (auscultating the epigastrium for bubbling as air is injected down the tube) and litmus testing of the aspirate. The whoosh test was positive while the aspirate from the tube turned blue litmus paper pink, suggesting gastric acidity. The tip had in fact punctured the pleura to lie in the pleural cavity. When enteral feed was administered through the tube her respiratory function worsened. The whoosh and litmus paper test were repeated. Again, they appeared to confirm the positioning of the tube in the stomach. Feeding continued and the girl died. At post mortem a l...

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Section: Possible Solutionsmentioning

confidence: 99%

Patient safety matters: reducing the risks of nasogastric tubes

Yardley¹,

Donaldson²

2010

Clinical Medicine

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“…Two papers in this journal, Garnerin et al 5 ( see page ) and Rhodes et al 6 ( see page ), report on programmes aimed at increasing compliance with logically designed protocols that seem capable of solving both the wrong patient problem and the wrong site problem. Some of the procedures specified by JCAHO also appear in the protocols of both Garnerin et al and Rhodes et al .…”

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confidence: 99%

“…Rhodes and colleagues6 evaluated the effects of an alert aimed at preventing wrong site surgery in NHS hospital trusts in England and Wales. The authors investigated “the response to the alert among clinicians... 12–15 months after it had been issued”.…”

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confidence: 99%

“…This has not been done for either wrong side surgery or identity errors. Both Garnerin5 and Rhodes6 have undertaken to protect the patient against the error, but do not speak to the question of why the error occurs or how to prevent it. Neither paper offers any suggestion as to the cause of the errors against which the authors erect plausible defensive strategies.…”

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confidence: 99%

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The egocentric surgeon or the roots of wrong side surgery

Senders¹,

Kanzki

2008

Quality and Safety in Health Care

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“…5 Instead, hospital administrators often measure safety and quality protocol compliance through peer audits, selfreport questionnaires, or chart audits. [6][7][8][9] Questionnaires and chart audits supply information conveniently, but these strategies alone may not be fully representative of universal protocol compliance and may not capture select components of the Joint Commission guidelines. For example, individual features of a hospital's universal protocol process may not be detailed in the chart, including correct incision site marking, display of appropriate radiographic images, discussion of pertinent patient care issues before incision, or "white board" filled out to completion.…”

Section: Introductionmentioning

confidence: 99%