Never Events X-Ray

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For the 2nd article in our series on NG Never Events we are focussing on the most common cause, the use of X-Rays to determine the positon of an NG Tube.

Strategic Executive Information System (StEIS) database and National Reporting and Learning System (NRLS) shows that of the 95 NG misplacement Never Events reported 45 (47%) were related to the use of x-rays1.

Of these incidents 40 were related to the misinterpretation of the x-ray, the other 5 were related to an x-ray being correctly interpreted but the wrong x-ray having been reviewed. An interesting finding is that while not all incident reports specifically stated that the person who misinterpreted the x-ray had not received training none of the reports seem to involved staff who had undertaken a competency based learning programme.  The report also found that the seniority of the clinicians involved ranged from junior doctors to consultants suggesting that when training programmes are put in place it is important that all grades of staff undertake them and not just those in junior roles.

If x-rays are the main cause of NG Never events is it possible to reduce their use in favour of methods with lower risk of error and and therefore reduce the overall risk of the use of a misplaced NG Tube?

One study that sheds light on what can be achieved in this regard is Taylor et al. (2014)1 which looked at a method of supporting changes in clinical behaviour and used decreasing the use of x-rays by supporting staff to use pH testing first line to check NG Tube position prior to feeding and/or medication administration in line with local and national guidance.

The results of this were dramatic increasing the use of pH testing from 14.1% prior to the intervention to 49.5% after it with reduction in x-rays from 60.2% down to 35.7%.  As well as reducing the risk of x-rays being misinterpreted the costs of tests was also reduced delivering substantial savings.

While the results were impressive it is important to consider that the interventions used in the study were significantly more far reaching and sustained than most hospitals would/could use to address the issue.  It is also interesting to note that the best results for any of the hospitals included for use of pH testing only achieved 72.7% after the intervention demonstrating that there was still a substantial gap to be bridged.

Next time; Never Events where pH testing associated with Never Events.

1 NHSI Resource set Initial placement checks for nasogastric and orogastric tubes July 2016

2Taylor et al. BMC Health Services Research (2014) 14:648 DOI 10.1186/s12913-014-0648-4