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Trusts ordered to review risk of death and harm through misplaced tubes

The risk of patients having fluids or medication passed into their respiratory systems through misplaced tubes is unacceptably high, NHS Improvement (NHSI) has said.

The regulator has issued a safety alert to all organisations where nasogastric or orogastric tubes are used for patients receiving NHS-funded care after finding that there were 95 incidents where tubes were wrongly inserted between September 2011 and March 2016.

In 32 of these incidents the patient subsequently died, although it is difficult to define whether the deaths were directly connected to the misplaced tubes because the patients were critically ill at the time.

Although this represented a small proportion of the 3 million tubes used by the NHS during this period, wrong insertion of tubes is a never event.

NHSI has now issued a stage two patient safety alert, used where there is a continuing risk of death and severe harm.

The most common cause of error was misinterpretation of X-rays intended to show where a tube is inserted.

Errors were also caused by problems with pH tests, unapproved tube placement checking methods, and communication failures which resulted in tubes not being checked.

However, the alert is aimed at trust boards, not frontline staff, in order to eliminate systematic safety failings which are leading to tubes being misplaced. These included allowing staff to insert tubes without the proper training, failure to include safety-critical tests in bedside documentation, and problems maintaining safe supplies of equipment.

By 21 April 2017, NHS trusts are required to identify named executive directors who will be responsible for the improvements, then undertaking an assessment of whether the organisation has the necessary safety systems and implementing an action plan to address any failings identified.

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