title: Discovering Innovation at the Intersection of Undergraduate Medical Education, Human Factors, and Collaboration: The Development of a Nasogastric Tube Safety Pack.
abstract: OBJECTIVE
  Significant deficiencies exist in the knowledge and skills of medical students and residents around health care quality and safety. The theory and practice of quality and safety should be embedded into undergraduate medical practice so that health care professionals are capable of developing interventions and innovations to effectively anticipate and mitigate errors.
  
  
  METHODS
  Since 2011, Leeds Medical School in the United Kingdom has used case study examples of nasogastric (NG) tube patient safety incidents within the undergraduate patient safety curriculum. In 2012, a medical undergraduate student approached a clinician with an innovative idea after undertaking an NG tubes root cause analysis case study. Simultaneously, a separate local project demonstrated low compliance (11.6%) with the United Kingdom's National Patient Safety Agency NG tubes guideline for use of the correct method to check tube position. These separate endeavors led to interdisciplinary collaboration between a medical student, health care professionals, researchers, and industry to develop the Initial Placement Nasogastric Tube Safety Pack.
  
  
  RESULTS
  Human factors engineering was used to inform pack design to allow guideline recommendations to be accessible and easy to follow. A timeline of product development, mapped against key human factors and medical device design principles used throughout the process, is presented. The safety pack has since been launched in five UK National Health Service (NHS) hospitals, and the pack has been introduced into health care professional staff training for NG tubes.
  
  
  CONCLUSIONS
  A mixed-methods evaluation is currently under way in five NHS organizations.
authors.affiliation: N. Taylor is senior research fellow, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia. T. Bamford is a fourth-year medical student, School of Medicine, Leeds Institute of Medical Education, University of Leeds, Leeds, Yorkshire, United Kingdom. C. Haindl is business development manager, Enteral UK, Selby, North Yorkshire, United Kingdom. A. Cracknell is a consultant geriatrician, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, Yorkshire, United Kingdom.
authors.forename: Natalie
authors.initials: N
authors.lastname: Taylor
authors.forename: Thomas
authors.initials: T
authors.lastname: Bamford
authors.forename: Cornelia
authors.initials: C
authors.lastname: Haindl
authors.forename: Alison
authors.initials: A
authors.lastname: Cracknell
mesh_terms: D003299:Cooperative Behavior; D003479:Curriculum; D004504:Education, Medical, Undergraduate / Q000379:methods; D006804:Ergonomics / Q000379:methods*; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007441:Intubation, Gastrointestinal / Q000592:standards*; D009936:Organizational Innovation; D061214:Patient Safety; D016730:Program Development; D011859:Radiography; D017010:Reminder Systems; D060891:Root Cause Analysis; D013222:State Medicine; D013270:Stomach / Q000000981:diagnostic imaging; D006113:United Kingdom