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Enhancing Patient Safety During Feeding‐Tube Insertion: A Review of More Than 2000 Insertions
Author(s) -
Sorokin Rachel,
Gottlieb Jonathan E.
Publication year - 2006
Publication title -
journal of parenteral and enteral nutrition
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.935
H-Index - 98
eISSN - 1941-2444
pISSN - 0148-6071
DOI - 10.1177/0148607106030005440
Subject(s) - medicine , feeding tube , psychological intervention , pdca , tube (container) , parenteral nutrition , surgery , operations management , quality management , nursing , mechanical engineering , management system , economics , engineering
Background: An intervention to reduce complications from insertion of small‐bore nasogastric feeding tubes was performed. Methods: This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding‐tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre‐ and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology‐guided insertion, and implementation of explicit policies and procedures. Results: Of all small‐bore nasogastric feeding‐tube placements, 1.3%–2.4% resulted in 50 documented cases of feeding‐tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding‐tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15‐month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the “number between” tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project. Conclusions: Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.