A Never Event occurred within the  United Lincolnshire Hospitals NHS Trust in December 2017 involving a misplaced nasogastric tube (NG-T).

In response to this, a multi-disciplinary working group was formed to undertake a rapid review of the processes and policies that were currently in place.

This rapid review was brought together and completed within one working week, with the policy being ratified and circulated within 2 weeks from commencement of the review. This was only possible because of the fantastic way that staff of all levels and across our sites all worked together to make this happen.

The staff involved included our team of Quality Matrons, Dieticians, Medical and Nursing staff, finance, procurement and secretarial support, not forgetting the ward staff who have responded very positively to this work. The use of the multi-disciplinary working group approach has elevated awareness of the potential risks of misplaced NG-T across the whole of the organisation and across all staff groups, whilst building good relationships and fostering good communication.

This has also enhanced patient safety. One of the major successes of the rapid review was the development of nasogastric tube insertion and management competencies for all practitioners, and the update of the NG management guidelines.

These have been ratified by Clinical Effectiveness Steering group and published on the Intranet.

An NG-T care bundle has also been produced to promote safe practice.

The process of implementing this competency framework has begun with simulated competency checks for tube insertion and usage being completed across the Trust.

A stratified approach has been used to target the high NG usage areas first. This will continue to be disseminated. We have worked with e-roster to enable this skill to be recorded to allow the Trust to share the wealth of expertise we have within our workforce.

Work is ongoing with regards to evidencing our compliance with the National patient safety Alert.

An action plan has now been created to provide Patient Safety Committee with oversight to ensure we can provide assurance around all aspects of nasogastric tube management. This work is now being followed up by the Nasogastric Task and Finish group.

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