A recent Patient Safety Alert issued by NHS Improvement asked trust boards to use a new resource set to assess whether previous alerts and guidance around the placement of nasogastric tubes have been implemented and embedded within their organisations. Dr Frances Healey provides her personal perspective on the continuing persistence of harm caused by misplaced nasogastric tubes from her experience both as a nurse and now as head of patient safety insight at NHS Improvement.
In 2003, I was holding the bleep for my hospital and woke to an early morning call from night staff explaining that during an attempted resuscitation they had realised the patient had been fed through a misplaced nasogastric tube. I drove through empty streets and undertook the painful task of contacting the patient’s family and breaking the news to the devastated doctor who had misinterpreted the x ray. Those of you who’ve been in the same position may recognise how very heavy a phone feels in those circumstances, and the effort of will it takes to press dial when you know that neither the family’s lives nor the staff member’s life will ever be quite the same.
Shortly after this, I moved into my first role in national patient safety and found I was not the only new arrival with a nasogastric tube death on my watch. The National Reporting and Learning System was still in its infancy, but through clinical contacts we brought together staff involved in 11 incidents to undertake a combined root cause analysis, and issued the first National Patient Safety Agency (NPSA) alerts in 2005.
These alerts succeeded in replacing some traditional (but unsafe) testing methods with pH paper and x ray. After a further 100 incidents, another NPSA alert was published in 2011. This emphasised the need for safe purchasing choices, for competency based training, and for structured documentation to reduce the risk of error in pH paper and x ray interpretation. An NPSA Rapid Response Report in 2012 and an NHS England alert in 2013 did not add any new guidance, but highlighted aspects of the 2011 alert that appeared to be misunderstood or disregarded.
A somewhat overused conference presentation slide runs along the lines of “patient safety isn’t rocket science…it’s much more complicated”. The phrase is used to make the point that changing training, policy, or documentation may be simple, but ensuring sustained and reliable implementation can be very challenging indeed. Sadly, our analysis of a further 95 incidents of feeding through misplaced nasogastric tubes showed that all too often it has been at the “it’s simple” end, where failure to implement earlier alerts appears to have occurred. For example, you clearly cannot expect to have staff with the right competencies for checking nasogastric tube placement unless your organisation has provided such training. Of course, there are incidents from the “much more complicated” end of the spectrum too, but many more in the area where hindsight might reasonably have been expected to be foresight. For example, where there is potential for new staff not to know local procedures or for documentation that was never audited to become documentation that was rarely completed.
On the basis of these findings, we issued a further National Patient Safety Alert to the NHS in England, emphasising that the most common problem that incident investigations found was the misinterpretation of x rays by medical staff who had never received competency based training in confirming nasogastric tube placement. This was not an issue that affected only junior or inexperienced staff, but staff of all grades and levels of experience.
Given the unprecedented number of alerts that had already been issued on this single topic, you might feel our decision now to issue yet another is an unreasonable triumph of hope over experience. So why have we done so?
Firstly, we hope these extra resources convey why it is vital to act on what has been learned the hard way through lost lives, damaged respiratory systems, and traumatised patients, families, and staff.
Secondly, we hope to simplify. We have brought together all the safety-critical elements of the many previous alerts, and drawn a clear line between these and the more general advice attached to earlier alerts that can and should fall into the zone of constantly evolving clinical guidance.
Thirdly, we want to ensure that the executive responsibility for ensuring the alert’s requirements are met before declaring “action completed”. I come to work each day because I sincerely believe that a national patient safety function can enable people to act on a harmful incident in one organisation before it is repeated elsewhere. But the ultimate responsibility for taking that shared learning forward lies with organisational leaders.
Healthcare professionals take very seriously their personal responsibilities to work within the limits of their competence, but that becomes problematic when staff “don’t know what they don’t know”. The incidents we looked at typically described staff who had not known that any special skills or knowledge were required. In some cases, staff were unaware that required competencies had changed since the days when just checking that the tip of the nasogastric tube appeared to be below the diaphragm was erroneously considered sufficient to exclude respiratory placement.
A safer system does not require every doctor or every nurse to obtain the knowledge and skills to confirm nasogastric tube placement, but it does require them to “know what they don’t know”. If you are unfamiliar with terms such as “the four criteria” for x-ray interpretation, the “safe range” for pH strips, or the tests that should never be used to confirm placement, then please seek appropriate training, and please avoid undertaking confirmation of nasogastric tube placement until you have done so.
I’d never met our patient who died in 2003, but in the following weeks of investigation and the inquest I felt like I had. It was very easy to picture what a warm and delightful husband, father, and grandfather he had been when I encountered the forgiveness and understanding his family extended to us. I cannot picture as clearly the patients affected by the 100 incidents I reviewed in 2011 or the 95 incidents I reviewed in 2016, but I am not a detached party in the journey of improving nasogastric tube safety; it feels painful and it feels personal. Please make acting now personal for you too.
Dr Frances Healey, RN, RN-MH, PhD
Head of Patient Safety Insight, NHS Improvement
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