Checking placement of nasogastric feeding tubes in adults (interpretation of x ray images): summary of a safety report from the National Patient Safety Agency

Safety Incidents in the Primary Care Office Setting

“…33 However, despite limitations from underreporting and reporting biases, analyses of NRLS data have played an important role in generating lessons to mitigate harmful incidents in other areas of clinical practice. 34,35 Incident report data offer a single lens on patient safety, and our findings must be interpreted cautiously alongside other data sources.…”

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice

“…157 However, despite limitations from under-reporting and reporting biases, analyses of NRLS data have played an important role in generating lessons to mitigate harmful incidents in other areas of clinical practice. 32,161 Incident-reporting culture Incident reporting is widely understood to be imperative for generating system learning that improves patient safety, 10,89,162 yet the literature demonstrates that patient safety incidents are under-reported. 19,81,104 As a result, there has been a great deal of interest in investigating barriers to medical incident reporting.…”

Use of pH Cutoff Level for Enteral Nutrition

“…Variable prevalence rates of misplacement are reported in the literature with initial misplacement or subsequent displacement occurring between 2 % and 43 % of the time (Sparks et al 2011;Ellett and Beckstand 1999;Farnington et al 2009;Wilkes-Holmes 2006). Over a 6-year period (2005)(2006)(2007)(2008)(2009)(2010) the National Patient Safety Agency (NPSA) reported 21 deaths and 79 cases of serious harm from misplaced NGT (Lamont et al 2011). Certain patient groups have been identified as being at higher risk of NGT misplacement which include those requiring mechanical ventilation (60 %) (Sparks et al 2011), critically ill patients (74 %) (Sorokin and Gottlieb 2006), and patients with a reduced level of consciousness (96 %) (Sorokin and Gottlieb 2006).…”

“…Radiographic interpretation errors accounted for 57 % of deaths and 57 % of serious incidents reported to the NPSA over a 6-year period (Lamont et al 2011). Interpretation error rates were more frequently reported among junior medical staff working late shifts (NPSA 2010a, b;Law et al 2013).…”