Blackpool Teaching Hospitals NHS Foundation Trust has issued a red alert after a ‘never event’ was recorded within the trust following a feeding tube being incorrectly placed within a patient’s airways
A red alert has been issued to staff at Blackpool’s NHS trust after a feeding tube was incorrectly placed into a patient’s airways instead of in their stomach.
The memo has been issued to all clinical staff at Blackpool Teaching Hospitals NHS Foundation Trust following the misplacement of a nasogastric (NG) tube in what has been labelled by the NHS as a ‘never event’ incident.
According to NHS England, never events are “serious incidents that are entirely preventable” because safety guidance at a national level “should have been implemented by all healthcare providers”.
The red alert, issued to staff on Tuesday (June 8), must now be communicated for a week at every shift handover.
LancsLive approached the hospital trust about what the outcome was for the patient, however the trust would not give any details due to patient confidentiality.
The memo, signed by trust Medical Director, Jim Gardner, and Director of Nursing, AHP and Quality, Peter Murphy, says that it is being circulated with staff “following the reporting by the trust of a Never Event incident involving the misplacement of an NG tube”.
It goes on to say that “introducing fluids or medication into the respiratory tract or pleura [layers overlying the lungs] via a misplaced nasogastric or orogastric tube is a Never Event”.
Staff have been told that checking the placement of NG tubes in patients via pH testing of aspirate or, when necessary, X-ray imaging is “essential in preventing harm”.
According to guidelines, the pH of gastric aspirate should be between one and five whereas respiratory aspirate is usually seven or higher; indicating whether the tube is placed correctly within a patient’s body so as to avoid foods, liquids or medicines being pumped into their airways.
The misplacement of an NG tube can result in serious injury and death, NHS England says.
NHS staff in Blackpool, which includes Blackpool Victoria Hospital, are also being told to double check if NG tubes are the “right decision” for the patients they are dealing with.
LancsLive is awaiting a statement from Blackpool Teaching Hospitals NHS Foundation Trust.
In March last year, investigations were launched after two never events at Blackpool’s NHS trust after the wrong lens was implanted into a patient’s eye.
The other incident involved a high dose of potassium being given to a patient in error.
Both events were described as wholly preventable by NHS England.
Thankfully, they did not lead to any significant harm.