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Re: Avoiding never events: Improving nasogastric intubation practice and standards
Clinical Radiology 68 (2013) 980e981
Contents lists available at SciVerse ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Correspondence
Re: Avoiding never events: Improving nasogastric intubation practice and standards Sir d As a junior doctor who has worked in medical, surgical, and intensive care environments, I have frequently been asked to check the proper intubation of not only nasogastric tubes, but also central venous catheters. Therefore, I read with interest the article by Law et al. (2013)1 regarding the misinterpretation of check images following nasogastric intubation. I would like to point out an additional oversight, not mentioned in the article, which can affect safe interpretation of line placements, particularly in patients with multiple check images on the picture archiving and communication system (PACS) archive. One can imagine that during a busy shift the verbal confirmation of correct placement, after quickly selecting the image from the PACS search, would lead to the patient being administered feeds and drugs almost immediately. It is altogether not implausible that one might select recent chest radiographs and deem them safe placements, before realizing the date and time refers to a previous line insertion. This oversight can have disastrous consequences. Although not mentioned in a literature search, an internet search does point to a recent memo from the Chief Medical Officer in Wales.2 A patient was fed via a misplaced nasogastric (NG) tube, which went undetected as the radiograph was “displayed in date but not time order. so the wrong image was checked.” This would be a useful learning point in teaching safe practice for check image interpretation, especially in settings such as critical care units and long-stay units.
References 1. Law RL, Pullyblank AM, Eveleigh M, et al. Avoiding never events: improving nasogastric intubation practice and standards. Clin Radiol 2013;68:239e44. 2. Jewell T. Re: Coroner’s Rule 43 letter regarding nasogastric tube placement. Ref.: CEM/CMO/2012/8b. 26th March 2012. Available at: http:// www.wales.nhs.uk/sites3/Documents/428/CEM%20CMO%202012%208b. pdf [Date accessed 27.03.13].
DOI of original article: http://dx.doi.org/10.1016/j.crad.2012.08.001.
J. George* Chelsea and Westminster Hospital, 369 Fulham Road, London SW3 6JJ, UK * Tel.: þ44 7809623289. E-mail address: [email protected] Ó 2013 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. http://dx.doi.org/10.1016/j.crad.2013.04.010
Re: Avoiding never events: Improving nasogastric intubation practice and standards. A reply Sir d I entirely agree with the concerns and advice of Dr Jewell in relation to Coroner’s Rule 43 regarding nasogastric tube placement1 referred to in Dr George’s letter. Image identification should include both date and time of acquisition, and the imaging index should identify all imaging in chronological order. The picture portrayed by Dr George’s letter was one of a busy shift resulting in rushed image selection and interpretation and the verbal communication of results. This is a marked deviation from good practice and will sooner or later result in errors, and possibly a “never event” occurring. In our paper,2 we emphasized that in North Bristol Trust written documentation is now mandatory from the decision to intubate to the confirmation of tube tip location, and only professionals competent to do so should document and sign the appropriate sections of the proforma kept in the patients notes. It is the responsibility and duty of care of the appropriate professionals involved at all stages of the intubation process to take care that the correct patient was intubated and the correct patient sent for check imaging. It is the duty of the image interpreter (whether radiologist or junior doctor) to make sure they have identified the appropriate image.
DOIs of original article: http://dx.doi.org/10.1016/j.crad.2012.08.001, http://dx.doi.org/10.1016/j.crad.2013.04.010.
Contents lists available at SciVerse ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Correspondence
Re: Avoiding never events: Improving nasogastric intubation practice and standards Sir d As a junior doctor who has worked in medical, surgical, and intensive care environments, I have frequently been asked to check the proper intubation of not only nasogastric tubes, but also central venous catheters. Therefore, I read with interest the article by Law et al. (2013)1 regarding the misinterpretation of check images following nasogastric intubation. I would like to point out an additional oversight, not mentioned in the article, which can affect safe interpretation of line placements, particularly in patients with multiple check images on the picture archiving and communication system (PACS) archive. One can imagine that during a busy shift the verbal confirmation of correct placement, after quickly selecting the image from the PACS search, would lead to the patient being administered feeds and drugs almost immediately. It is altogether not implausible that one might select recent chest radiographs and deem them safe placements, before realizing the date and time refers to a previous line insertion. This oversight can have disastrous consequences. Although not mentioned in a literature search, an internet search does point to a recent memo from the Chief Medical Officer in Wales.2 A patient was fed via a misplaced nasogastric (NG) tube, which went undetected as the radiograph was “displayed in date but not time order. so the wrong image was checked.” This would be a useful learning point in teaching safe practice for check image interpretation, especially in settings such as critical care units and long-stay units.
References 1. Law RL, Pullyblank AM, Eveleigh M, et al. Avoiding never events: improving nasogastric intubation practice and standards. Clin Radiol 2013;68:239e44. 2. Jewell T. Re: Coroner’s Rule 43 letter regarding nasogastric tube placement. Ref.: CEM/CMO/2012/8b. 26th March 2012. Available at: http:// www.wales.nhs.uk/sites3/Documents/428/CEM%20CMO%202012%208b. pdf [Date accessed 27.03.13].
DOI of original article: http://dx.doi.org/10.1016/j.crad.2012.08.001.
J. George* Chelsea and Westminster Hospital, 369 Fulham Road, London SW3 6JJ, UK * Tel.: þ44 7809623289. E-mail address: [email protected] Ó 2013 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. http://dx.doi.org/10.1016/j.crad.2013.04.010
Re: Avoiding never events: Improving nasogastric intubation practice and standards. A reply Sir d I entirely agree with the concerns and advice of Dr Jewell in relation to Coroner’s Rule 43 regarding nasogastric tube placement1 referred to in Dr George’s letter. Image identification should include both date and time of acquisition, and the imaging index should identify all imaging in chronological order. The picture portrayed by Dr George’s letter was one of a busy shift resulting in rushed image selection and interpretation and the verbal communication of results. This is a marked deviation from good practice and will sooner or later result in errors, and possibly a “never event” occurring. In our paper,2 we emphasized that in North Bristol Trust written documentation is now mandatory from the decision to intubate to the confirmation of tube tip location, and only professionals competent to do so should document and sign the appropriate sections of the proforma kept in the patients notes. It is the responsibility and duty of care of the appropriate professionals involved at all stages of the intubation process to take care that the correct patient was intubated and the correct patient sent for check imaging. It is the duty of the image interpreter (whether radiologist or junior doctor) to make sure they have identified the appropriate image.
DOIs of original article: http://dx.doi.org/10.1016/j.crad.2012.08.001, http://dx.doi.org/10.1016/j.crad.2013.04.010.