Avoiding never events: improving nasogastric intubation practice and standards.

Area of Science:

• Medical Safety
• Clinical Practice Improvement
• Patient Care

Background:

• Nasogastric (NG) intubation is a common procedure with potential risks.
• A "never event" highlighted critical weaknesses in NG intubation practices.
• Patient safety requires continuous monitoring and improvement in clinical procedures.

Purpose of the Study:

• To identify and rectify deficiencies in NG intubation practices.
• To reduce the incidence of NG tube misplacement.
• To enhance patient safety following a "never event".

Main Methods:

• Root-cause analysis to understand practice failures.
• Implementation of recommendations across documentation, intubation, and training.
• Prospective audit and re-audit to assess the impact of changes.

Main Results:

• Significant improvements in documentation accuracy (22% increase).
• Reduction in junior doctor image interpretation errors (from seven to one).
• Development of new protocols for NG tube check imaging.

Conclusions:

• Enhanced awareness and improved image interpretation have increased patient safety.
• Radiology departments should lead in developing safe NG tube interpretation practices.
• While improved, continuous vigilance is needed to prevent "never events".