title: Risk management, or just a different risk?
abstract: BACKGROUND
  National reporting of adverse incidents has resulted in a number of clinical alerts being issued. Despite a lack of evidence, these alerts are often accompanied by a mandatory requirement to alter practice. There is likely to be clinician resistance to such a method of change management, particularly where evidence of safety is missing.
  
  
  OBJECTIVE
  To determine the level of implementation within neonatal units of an alert requiring the change from litmus to pH paper to test nasogastric tube position.
  
  
  METHODS
  A questionnaire sent to all neonatal units in the United Kingdom with more than 12 cots.
  
  
  RESULTS
  From the 207 questionnaires sent, there were 165 (80%) responses. Fifty five percent of units were still using litmus. All continued to use supplementary tests not recommended in best practice statements issued at the time of the alert. There was considerable variation in the pH value at which it was considered safe to feed.
  
  
  CONCLUSIONS
  Nine months after the alert, more than half the units had not changed to pH paper, and supplementary methods of testing were still being used. The wide range of pH values highlights the uncertainty about the "normal" gastric pH in the newborn. The evidence that, in neonatal units, changing to pH paper is safer than the long established use of litmus is lacking. Recommendations for change in practice must be based on good information and not seen just as a "knee jerk" response to adverse incidents.
authors.affiliation: Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, Scotland, UK.
authors.forename: Y
authors.initials: Y
authors.lastname: Freer
authors.forename: A
authors.initials: A
authors.lastname: Lyon
mesh_terms: D019317:Evidence-Based Medicine; D005547:Foreign Bodies / Q000175:diagnosis / Q000209:etiology; D005745:Gastric Acidity Determination; D019983:Guideline Adherence / Q000706:statistics & numerical data; D019538:Health Care Surveys; D006302:Health Services Research / Q000379:methods; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007202:Indicators and Reagents; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000592:standards* / Q000706:statistics & numerical data; D007441:Intubation, Gastrointestinal / Q000009:adverse effects / Q000379:methods* / Q000592:standards; D017410:Practice Guidelines as Topic; D011364:Professional Practice / Q000706:statistics & numerical data; D012308:Risk Management / Q000379:methods*; D013222:State Medicine; D006113:United Kingdom
chemical_list: D007202:Indicators and Reagents