title: Avoiding never events: improving nasogastric intubation practice and standards.
abstract: OBJECTIVE
  To identify and rectify weaknesses in nasogastric (NG) intubation practice in the North Bristol NHS Trust that resulted in the occurrence of a National patient Safety Agency defined "never event".
  
  
  METHODS
  Root-cause analysis identified that a change in culture was required. Recommendations divided into four categories: documentation, intubation, interpretation training, and radiology. A 6 month prospective audit covering all aspects of NG intubation practice preceded implementation of the recommendations. All patients whose tubes were mis-sited formed the cohort of the study. A re-audit was undertaken 12 months after the implementation of the recommended changes.
  
  
  RESULTS
  Re-audit suggested significant improvements had occurred in all categories, particularly junior doctor check image interpretation errors, which in the study group were reduced from seven to one, and documentation, which has so far improved by 22%. Protocols and guidelines associated with NG tube check imaging have now been developed for radiologists and radiographers with check imaging and image interpretation being made a priority and respiratory tract intubation treated as an emergency.
  
  
  CONCLUSIONS
  The service is still not perfect, but there is a focal awareness of patient safety associated with intubation practice, and image interpretation by junior doctors significantly improved with the introduction of the e-learning package. However, it is considered that the responsibility for developing safe practice with respect to NG tube check image interpretation ultimately lies with the department of radiology, which should take the lead on reducing the risk of never events being caused by the misinterpretation of these images.
authors.affiliation: Department of Radiology, North Bristol NHS Trust, Bristol, UK. Law@voxcot.freeserve.co.uk
authors.forename: Robert L
authors.initials: RL
authors.lastname: Law
authors.forename: Ann M
authors.initials: AM
authors.lastname: Pullyblank
authors.forename: Mark
authors.initials: M
authors.lastname: Eveleigh
authors.forename: Nicola
authors.initials: N
authors.lastname: Slack
mesh_terms: D002983:Clinical Competence; D004282:Documentation / Q000592:standards; D004739:England; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000592:standards*; D019300:Medical Errors / Q000517:prevention & control; D061214:Patient Safety / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D058996:Quality Improvement; D011871:Radiology / Q000193:education / Q000592:standards*