Summary
Misplacement of nasogastric tubes can have disastrous consequences for patients and is listed as a “never event” by NHS England. When Lancashire Teaching Hospitals NHS Foundation Trust had two of these never events, the nutrition nursing team carried out a system-wide evaluation to identify problems and develop plans to address them.
An e-learning package, robust standardisation in staff’s approach to patient care, re-setting “red lines” to support and empower staff, and the introduction of monitoring and reporting systems have contributed to improving patient safety.
Improving safety with nasogastric tubes: a whole-system approach (Nursing Times, 2019)
https://www.nursingtimes.net/clinical-archive/patient-safety/improving-safety-with-nasogastric-tubes-a-whole-system-approach-25-11-2019/
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