Medical equipment, perhaps in ventilator in intensive care ICU Source: Ingimage
An investigation into the incorrect placement of nasogastric (NG) tubes found there was “no systemic barriers” to prevent this from happening and that action was needed to improve staff competency training.
Hospital staff informing the inquiry also said that guidance on the insertion of NG tubes was “too long to read”.
“Staff told the investigation they know the guidance is there, but such guidance is too long to read”
HSIB report
The latest report by the Healthcare Safety Investigation Branch (HSIB) focuses on the life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients.
Feeding tubes were mistakenly inserted into people’s lungs more than a dozen times between April and September, new data shows.
The so-called ‘never event’ – when nasogastric (NG) equipment was incorrectly placed – occurred 14 times in England over the six-month period, according to analysis by the Healthcare Safety Investigation Branch (HSIB).
Covid-19 measures made inserting the tubes – which deliver food, liquid or medication to critically ill patients – more challenging, the report said.
Problems such as access to clinical notes in restricted Covid-19 areas in hospitals meant that investigation into misplaced NG kit was not as quick, and “reflected pressures on the system at that time”, the HSIB said.