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This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. The National Patient Safety Team were notified by a trust Medical Device Safety Officer (MDSO) of an incident where a baby ingested the cap off a purple colostrum syringe. The baby was being fed expressed colostrum by the parent who was unaware of the presence of the cap when the feed started . Colostrum is the first breast milk the mother produces providing important nutritional benefits for newborns. When pressure was placed on the syringe plunger accidental cap dislodgement occurred and the baby required surgery to remove the cap. Despite the purple colour, the syringe was not licenced for the administration of colostrum. Collaboration with the MHRA resulted in the issuing of a device safety information alert. Working with key midwifery and neonatal stakeholders, a safety communication on reducing the risk of choking was issued to maternity and neonatal units. When advised of the safety issue, the manufacturer ceased production of the syringe and have introduced a new licenced colostrum collection and administration syringe. The new syringe does not have a cap and is available to order from the NHS Supply Chain. This intervention should reduce the risk of accidental ingestion of syringe caps.

Parenteral nutrition (PN) is recognised as a complex high-risk therapy. Its practice is highly variable and frequently suboptimal in paediatric patients. Optimising care requires evidence, consensus-based guidelines, audits of practice, and standardised strategies. Several paediatric scientific organisations, expert panels, and authorities have recently recommended that standardised PN should generally be used over individualised PN in the majority of paediatric patients including very low birth weight premature infants. In addition, PN admixtures produced and validated by a suitably qualified institution are recommended over locally produced PN. Licensed multi chamber bags are standardised PN bags that comply with Good Manufacturing Practice and high-quality standards for the finished product in the frame of their full manufacturing license. The purpose of this article, published in Clinical Nutrition, is to review the practical aspects of PN and the evidence for using such multi-chamber bags in paediatric patients. It highlights the safety characteristics and the limitations of the different PN practices and provides some guidance for ensuring safe and efficient therapy in paediatric patients.

Baby Jimmy was being breastfed within a baby carrier worn by his mother. After 5 minutes she found that he was collapsed and although immediate resuscitation was commenced he died 3 days later on 11 October 2023 in St George’s Hospital. Jimmy died because his airway was occluded as he was not held in a safe position while within the sling. There is insufficient information available from any source to inform parents of safe positioning of young babies within carriers and in particular in relation to breastfeeding.  It was accepted that the sling was being worn snugly, not tightly, and although she could see his face when she looked down, the TICKS acronym was not met by his position within the sling as Jimmy was too far down. The TICKS acronym was prepared by the (now disbanded) UK consortium of sling retailers and manufacturers tight in view at all times close enough to kiss keep chin off the chest supported back. There appeared to be no advice in the literature regarding the risk of baby slumping and the risk therefore of suffocation, particularly if baby is under the age of 4 months, and no advice that breastfeeding “hands free” a young baby is unsafe, due to the risk of suffocation and not being able to meet every aspect of TICKS. There appeared to be no helpful visual images of “safe” versus “unsafe” sling/carrier postures. Evidence was given by the witnesses assisting the inquest that public information, readily available, not too complex but consistent in message would be welcomed to advise and instruct. Matters of concern There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings This is notwithstanding a significant increase over recent years in the use of such equipment. The question of whether it is safe to breastfeed “hands free” is not addressed or referred to in the public domain or manufacturers literature. The NHS available literature provides no guidance or advice. The only current “tips” are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful Young babies are at risk of suffocation. Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.

Statistics and key facts about the impact of hydration, nutrition, sleep, and regular breaks on workforce wellbeing.

Continuing Professor Martin Langham's 'Why investigate' blog series, colleague Bobbie Enright turns to the topic of fatigue, looking at the causes and preventions, how it can impact on our work and how we can manage it. Martin has managed over the course of his blogs to open our eyes to the world of Human Factors (HF) and, in particular, the area of HF within the medical world. What hasn’t been touched on yet is the topic of fatigue. Why am I mentioning this dreaded word, you ask. Well, unfortunately it impacts all of us. In fact, I would be prepared to bet a lot of money that we have all experienced fatigue at some point. And I will point out that I am not a gambling person, so hopefully that indicates to you how certain I am, but also unfortunately points out the prevalence. Right now we’re all under a great deal of strain; we hear the media talking about stress and mental health and workload. Some people are having flashbacks to the war with references to ‘doing our bit’. In fact, my 94 year old grandfather is adamant that I have it worse right now living through this time than he did living and serving through the war period. In our conversations I have disagreed with him, but upon reflection I can see his point. We live in an instant age, we’re not used to sitting and waiting. Working from home means that despite being remote from our colleagues, we are still accessible. That work pressure still exists and, arguably, it is greater than ever. We are separated from our colleagues, our friends and our families. Of course not all of us are working from home. There are those of us who are still attending the workplace. But again, this is no longer the same; our colleagues cannot come close to us, our words are slightly muffled, we realise how much we rely on lip movement to understand speech. We realise we are removed from others, we realise our workload has multiplied and we realise we are drowning. But, before our heads go under… This stress, this anxiety, this impact on our mental health – perhaps it has a cause we haven’t considered. Perhaps the cause is something we thought was a symptom. Perhaps we are fatigued. So, what is fatigue exactly? Let’s stop bandying this word around and actually get to grips with it. We can attempt to define it, look at some symptoms, some causes and hopefully you can learn some tips on how to deal with fatigue. I should give a disclaimer here – I am not a fatigue expert and it would be arrogant for me to state that. However, I do work within the field of Human Factors. I look at how we as humans interact with the world around us and how we can make that better and safer. I look at what impacts on our ability to do well and a consequence of fatigue is that our performance in our tasks declines. Suffice to say I have made it my business to learn. Fatigue, unfortunately, doesn’t have one single definition. But I’ll attempt to give it a go. Fatigue is a subjective feeling of extreme tiredness. It is likely to have a gradual onset and may come from mental or physical exertion or alternatively be caused by a medical condition (diagnosed or not). Our task performance and decision making abilities are negatively impacted. Concentration decreases and our mind is foggy. It is not the same as finishing an intense gym workout and wanting to lie down. You may not realise you are fatigued as we are very good at ignoring our bodies trying to tell us something is wrong. Across the western world, high levels of fatigue are significantly associated with excessive mortality rates and it is increasingly being recognised as strongly associated with poor long-term quality of life and negatively impacting on our work ability. Essentially, it is being recognised as a problem in more than one aspect of our lives. How do I know if I’m fatigued? Well that is a good question and, as we’ve said, fatigue is a subjective feeling. The warning signs I experience can be different to those experienced by somebody else or the degree to which I experience symptoms could be different. Some key signs are frequent blinking, struggling to keep your eyes open, tiredness that doesn’t improve after sleep, constant headaches, blurred vision, being prone to irritability, slower reflexes and thinking, micro-sleeps, impaired decision making and muscles feeling achy and/or weak. There are some signs where it is important to see your doctor. Lifestyle or work demands are often the cause of fatigue, but where fatigue could be connected to a medical issue it is always worthwhile seeking professional advice. These are generally symptoms such as vomiting, shaking or shortness of breath, but depression is also commonly linked to fatigue. If I’ve noticed the signs can I work out what caused it? As mentioned above, fatigue can be linked with medical conditions. Obesity, insomnia, depression, anaemia, low general health can all be causes of – and conversely symptoms of – fatigue. Some medications can also list fatigue as a side effect. Our age and lifestyle also impact the likelihood of fatigue. Younger members of the population are more likely to experience non-medical fatigue, and drug and alcohol use increases the risk across all age groups. Our need to juggle the multiple daily responsibilities – bills, kids, pets, commuting, laundry, food prep, etc – also causes fatigue. This is important to remember because it is so easy to judge ourselves for struggling to do all of this and to decide to get up early and get tasks done, forfeiting sleep and rest. We don’t necessarily realise that this creates a vicious cycle where we find it harder to cope and take longer to finish tasks because we are fatigued so we deprive ourselves of rest in order to get things done ad infinitum. Of course work factors do also positively correlate with the likelihood of fatigue, particularly if you are a shift worker or your role involves long driving hours, e.g., train/bus/HGV driver/pilot. You can imagine that this is due to the stressful demands of the role, which is absolutely correct. But interestingly, when we are experiencing underload we can also experience fatigue because our brains essentially ‘switch off’, e.g., driving on a long, straight, empty stretch of road. Well it’s all good knowing I’m fatigued, but what can I do about it? Let’s talk coping mechanisms – when we start to flag we often use coping mechanisms to keep going. Sugary foods and drink and caffeine are some of the things we automatically reach for. We see our favourite TV characters grab an energy drink or a coffee to keep them going as they study for exams/cover another shift/track down the bad guy, ad nauseam. Unfortunately these coping mechanisms only give us a short burst before we feel just as fatigued as we did before, if not worse – in fact, how often do we see the above characters crash at the end of the episode after they’ve relied on coffee!? This doesn’t mean you can’t have a coffee, etc, it’s rather just a flag to remind ourselves that it doesn’t solve the problem and we need to think about our behaviours. If we have a coffee too late in the day, we could then struggle to fall asleep afterwards. However, if we use the coffee as a break earlier on in the day it not only acts as a stimulant, but the act of consciously taking a break from our task to get the coffee can be beneficial. Similarly, getting some fresh air benefits us by stepping away from our task and going outside – a mental and physical break. However, what we should really be doing is trying to prevent ourselves from reaching the point of fatigue so we’re not reliant on stimulants or coping mechanisms. Having a routine is important. This is something we provide for our children and instil in them for years and seem to promptly forget once we reach adulthood. Going to bed and getting up at the same time each day creates a ‘defence’ against fatigue because our bodies have an expectation of what is required. This is of course assuming we have allowed sufficient time to sleep – this differs for everyone, but I am firmly in the ‘needing 8 hours sleep’ camp. Usually, getting between 7 and 9 hours sleep is recommended. Including regular exercise into our daily lives is equally as important. This helps to keep our bodies healthy and helps with attaining quality sleep. Diet should also be mentioned. The types of food we eat doesn’t just impact our general health, but it impacts on our ability to rest and sleep as well as feeding our brains. If we don’t eat enough nutritious food we can struggle to concentrate and eating large or heavy meals before bed can negatively impact our sleep. Unfortunately, there’s nothing we can really do to prevent fatigue entirely. There’ll always be a time when we experience it to some extent, but knowing what tends to trigger your fatigue will definitely help you to avoid it to the most part. Are you still awake? At this point I think I should ask the question "Are you still awake?" You may have noticed that there can be something quite soporific about the topic of fatigue – and yes I have yawned during the writing of this – although I think this would take many further blogs to attempt to delve into the psychological implications here. There should be no expectation for us all to become experts of our own fatigue and the causes and preventions. But we need to allow ourselves to acknowledge that we’re struggling and attempt some introspection as to the cause. Because remember, our fatigue could be related to our lifestyle or it could be related to a medical issue. Realistically, we probably do notice our fatigue and combat it successfully, but this is likely often on a subconscious level as just a part of our everyday lives. Hopefully the above insights can help you manage fatigue effectively day-to-day. Read the other blogs in this series Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5. How or Why. Part 6 Why investigate? Part 7 – The questions and answers Why investigate? Part 8 – Why an ‘It’s an error trap conclusion’ is an error trap Why investigate? Part 9 – Making wrong decisions when we think they are the right decisions Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research

Use of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005 and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.’ Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, these incidents show that risks to patient safety persist. Checking tube placement before use via pH testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm. Actions Who: All organisations where nasogastric or orogastric tubes are used for patients receiving NHS-funded care. Identify a named executive director who will take responsibility for the delivery of the actions required in this alert. Using the resources supplied with this alert, undertake a centrally coordinated assessment of whether your organisation has robust systems for supporting staff to deliver safety-critical requirements for initial nasogastric and orogastric tube placement checks. If the assessment identifies any concerns, use the resources supplied with this alert to develop and implement an action plan to ensure all safety-critical requirements are met. S hare this assessment and agree any related action plan within relevant commissioner assurance meetings. Share the key findings of this assessment and the main actions that have been taken in the form of a public board paper.

This article looks at NHS safety advice on reducing the harm caused by nasogastric feeding tubes that have been wrongly inserted. The alert, from the National Patient Safety Agency, followed 11 deaths of patients in two years, including that of one child.

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 head of patient safety insight at NHS Improvement.  

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.