The report was spurred by the case of a young man who had a tube accidentally placed into his lungs while being treated in a critical care ward following a cycling accident. He was then given liquid feed into his lungs for two days before the error was detected.
In addition to the most recent case, the HSIB found 14 incidents of misplaced nasogastric tubes from April-September and said COVID-19 has added to the challenges around confirming correct intubation. Correct tube placement can be confirmed by pH testing or x-ray imaging.
The HSIB recommends the British Society of Gastrointestinal and Abdominal Radiology (BSGAR) work with the College of Radiographers (CoR) and Health Education England (HEE) to develop a national training program for x-ray-based confirmation of tube placement. It would also be beneficial for critically ill patients with tubes to have their x-rays confirmed by a radiologist or appropriately trained radiographer, the report added.
Following the report, the Royal College of Radiologists (RCR) and BSGAR will explore training options with CoR and HEE in the new year.
To read the full report, click here.
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