Acceptability of a new practice development for radiographers focussed on reducing ‘never events’ related to nasogastric feeding tubes in adult patients

Roe, G.; Lambie, Hannah; Hood, Antoinette F.; Tolan, Damian

doi:10.1016/j.radi.2019.02.002

Cited by 9 publications

(22 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Sixty-four full-text studies were obtained and screened after the titles and abstracts were screened, and 52 were excluded. Finally, 12 articles (17,18,(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) were included and used for qualitative synthesis in this review (Figure 1). The excluded articles were due to (1) studies that did not have a reference group (n = 23), (2) studies that did not include implementation strategies to improve high-value verification methods of NGT placement (n = 16), and (3) other (e.g., full text was not available, no outcomes showed on the volume of the high-value method, combined results of pH/X and other methods) (n = 13).…”

Section: Search and Screening Resultsmentioning

confidence: 99%

“…Most studies were performed in the United States (USA) (n = 4) (17,22,25,28) and the United Kingdom (UK) (n = 4) (20,23,24,27). Of the 12 included studies, three focused their implementation strategy on improving pH testing (17,26,29), three on improving X-ray (23)(24)(25), and six on improving these two methods (18, 20-22, 27, 28). Of the 9 studies (17,18,(20)(21)(22)(26)(27)(28)(29) that used pH testing, four used a pH level of 5.5 as the cutoff point (20,26,27,29), three used a pH level of 5 as the cutoff point (17,18,22), one used a pH value of 4 as the cutoff point (28), and one used a pH value of 6 as the cutoff point (21).…”

Section: Characteristics Of the Included Studiesmentioning

confidence: 99%

See 1 more Smart Citation

Effects of implementation strategies aimed at improving high-value verification methods of nasogastric tube placement: A systematic review

Sun

Nicholas

2022

Front. Nutr.

View full text Add to dashboard Cite

BackgroundX-ray and pH testing, which clinical practice guidelines have proven to be effective in determining nasogastric tube (NGT) placement, were named the high-value methods. Implementation strategies can help to integrate high-value methods into particular contexts. The aim of this systematic review was to summarize the evidence of implementation strategies aimed at improving high-value verification methods of NGT placement.MethodsPubMed, ProQuest, and CINAHL were searched until June 2022. The Cochrane Effective Practice and Organization of Care (EPOC) taxonomy was used to categorize implementation strategies.ResultsThe initial search identified 1,623 records. Of these, 64 full-text studies were reviewed. Finally, 12 studies were included and used for qualitative synthesis. Eleven studies used an education component as an implementation strategy. Only one study based their implementation strategy on a barriers and facilitators assessment. None of the studies reported enough detail of the implementation strategy used in their studies. Seven studies were eligible for inclusion in the meta-analysis. Three of these seven studies revealed a significant improvement of the high-value method after strategy implementation. As heterogeneity was present in the high level, the pooled effect estimated was not calculated.ConclusionMost studies used an implementation strategy with an educational component. Unfortunately, no conclusion can be drawn about which strategy is most effective for improving high-value verification methods of NGT placement due to a high level of heterogeneity and a lack of studies. We recommend that future studies fully connect their implementation strategies to influencing factors and better report the details of implementation strategies.Systematic review registration[www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022349997].

show abstract

Section: Search and Screening Resultsmentioning

confidence: 99%

Section: Characteristics Of the Included Studiesmentioning

confidence: 99%

Effects of implementation strategies aimed at improving high-value verification methods of nasogastric tube placement: A systematic review

Sun

Nicholas

2022

Front. Nutr.

View full text Add to dashboard Cite

show abstract

“…The pathway and process for paediatrics, however, necessitated several changes from the adult nasogastric tube commenting system. For example, if a misplaced nasogastric tube is identified in an adult, it is removed by the radiographer whilst the patient is in the radiology department [ 10 , 18 ]. Given the complexity of some children with nasogastric tubes at our institution, the potential distress caused, and the risks of removing an nasogastric tube unnecessarily, radiographer removal of nasogastric tubes in children was not considered appropriate.…”

Section: Discussionmentioning

confidence: 99%

“…Radiographers at our institution have greatly appreciated the opportunity for role extension through commenting on nasogastric tubes in both adult and paediatric practice and have played an important role in improving patient safety [ 18 ]. The commenting pathway was initially introduced to provide an immediate opinion on nasogastric tube position for radiographs requested under a specific nasogastric tube check radiograph code.…”

Section: Discussionmentioning

confidence: 99%

Immediate chest radiograph interpretation by radiographers improves patient safety related to nasogastric feeding tube placement in children

et al. 2021

View full text Add to dashboard Cite

Background Despite the publication of a national patient safety alert in 2016, inadvertent feeding through misplaced nasogastric tubes continues to occur, either through failure to review the radiograph, misinterpretation of it, or failure to communicate the results. Objective The objectives were to determine whether training in a new pathway introduced to avoid these “never events” was followed and whether radiographer comments and prompt communication of results could reduce risk and improve patient safety in relation to nasogastric tube placement in children. Materials and methods Following radiographer training in interpretation of nasogastric tube position and use of a commenting proforma and communication pathway, we reviewed all radiographs obtained to check nasogastric tubes performed over a 13-month period in children 0–16 years of age. Then we assessed accuracy of the radiographer comments, adherence to the pathway, and any practice change in children with misplaced nasogastric tubes. Results We reviewed 282 nasogastric tube check radiographs. For 262 radiographs (92.9%) the pathway was followed correctly. Of the total 282 radiographs, 240 (85%) were immediately reported using the standardised commenting proforma, and 235 radiographer comments were affirmed by the radiologist (97% accuracy, confidence interval 0.95–0.99). Of the immediately reported radiographs, 213 (88.8%) nasogastric tubes were considered to be safe for use. Four (1.7%) of the immediately reported nasogastric tubes were misplaced in a bronchus, and the report communicated to the clinical team resulted in removal or re-siting of the tubes. Conclusion Nasogastric tube check radiographs in children can be reported accurately by radiographers trained in their interpretation and the results promptly communicated to clinical staff, improving safety in relation to nasogastric tube placement in children.

show abstract

“…For example, the occurrence of severe injury due to misplacement of nasogastric tubes, a defined "never event," has led to several investigations, and development and evaluation of new practices addressing real-time image interpretation issues among radiographers in the United Kingdom. [18][19][20] Including wrong tooth extraction explicitly as a subcategory of wrong-site surgery lead to an increase in professional activity related to "never event" definition and prevention in dentistry. 21,22 Professional activities are motivated and strengthened if it is clear that serious events continue to happen, abstracted from the singular event at a single hospital.…”

Section: Discussionmentioning

confidence: 99%

Registration and Management of “Never Events” in Swiss Hospitals—The Perspective of Clinical Risk Managers

Schwappach

Pfeiffer

2020

J Patient Saf

View full text Add to dashboard Cite

Background: In Switzerland, there is no mandatory reporting of "never events." Little is known about how hospitals in countries with no "never event" policies deal with these incidents in terms of registration and analyses. Objective: The aim of our study was to explore how hospitals outside mandatory "never event" regulations identify, register, and manage "never events" and whether practices are associated with hospital size. Methods: Cross-sectional survey data were collected from risk managers of Swiss acute care hospitals. Results: Clinical risk managers representing 95 hospitals completed the survey (55% response rate). Among responding risk and quality managers, only 45% would be formally notified through a designated reporting channel if a "never event" has happened in their hospital. Averaged over a list of 8 specified events, only half of hospitals could report a systematic count of the number of events. Hospital size was not associated with "never event" management. Respondents reported that their hospital pays "too little attention" to the recording (46%), the analysis (34%), and the prevention (40%) of "never events." All respondents rated the systematic registration and analysis of "never events" as very (81%) or rather important (19%) for the improvement of patient safety. Conclusions: A substantial fraction of Swiss hospitals do not have valid data on the occurrence of "never events" available and do not have reliable processes installed for the registration and exam of these events. Surprisingly, larger hospitals do not seem to be better prepared for "never events" management.

show abstract

Acceptability of a new practice development for radiographers focussed on reducing ‘never events’ related to nasogastric feeding tubes in adult patients

Cited by 9 publications

References 11 publications

Effects of implementation strategies aimed at improving high-value verification methods of nasogastric tube placement: A systematic review

Effects of implementation strategies aimed at improving high-value verification methods of nasogastric tube placement: A systematic review

Immediate chest radiograph interpretation by radiographers improves patient safety related to nasogastric feeding tube placement in children

Registration and Management of “Never Events” in Swiss Hospitals—The Perspective of Clinical Risk Managers

Contact Info

Product

Resources

About