In the previous instalments in our series looking at NGT Never Events we looked at the incidence of Never Events overall and then in the last issue at NG Never Events caused by misinterpretation of X-Rays. In this issue we examine the detail around the NG Never Events attributed to issues connected with pH Testing.
In a report, last year1, out of 95 NGT Never Events reported through the UK Strategic Executive Information System (StEIS) database and National Reporting and Learning System (NRLS) 23 Incidents (24%) were categorised as relating to pH testing using currently available technology and methodology.
Unlike the analysis of the X-Ray related incidents the underlying (Root) causes were not always clearly established for the pH related incidents which perhaps suggests that complexities in the interaction between the test itself and the related human factors is a significant part of the causes and these are difficult to pin down.
The Table below shows an interpretation of the potential reasons allocated as well as possible the authors of the report based on the data submitted by the investigators of the incidents. It should be noted though that 10 incidents had no clear cause but for these the report authors observe that this was due to the inadequacy of the information provided for example whether the pH paper used was appropriate for testing gastric aspirate or whether staff had received competency based training. In 2 of the incidents where no clear cause was found the authors observe that there may have been fluid introduce prior to testing and in 3 others describe a gap between testing and the NG Tube being used. In the other 5 incidents in this category the pH results was described as being in “the safe range” but this is not specified what this range was considered to be.
As with X-Rays seniority of staff involved did not seem to be a factor in determining the likelihood of a pH related Never Event and one observation on this is to question whether all staff receive competency based training or whether this is sometimes deemed unnecessary for senior staff. Another factor related to training is that only one of the reports into incidents related to pH being a factor in Never Events stated that the member of staff involved had had competency based training.
From the above analysis, it is clear that there is still a long way to go in order to improve patient safety with regard to NGT related Never Events and many of the factors involved could be removed or significantly reduced in frequency by the application of new options such as NGPOD.
1NHSI Resource set Initial placement checks for nasogastric and orogastric tubes July 2016