APPENDIX 2 AREAS FOR SELF ASSESSMENT Main subject Heading Requirements/Standards Gap analysis RAG Rating Policy Are you confident local policies and protocols accurately reflect all the safety-critical requirements summarised in this resource Are you confident policies and protocols are clear and accessible to frontline staff? National safety In comparing what happened with ‘what Are you confident that guidance should have happened’, investigation investigators refer to This needs to be summaries almost never refer to NPSA formal sources of referred to in any alerts or actions required within them, guidance, such as Patient incident investigation and appear to rely on local policy or the Safety Alerts or NICE investigators’ understanding of good guidance to set the practice. standard on ‘what Some investigations showed an apparent should have happened’ lack of understanding by investigators of as part of any how nasogastric tube placement should investigation? be checked on x-ray, and one investigation report suggests the investigator thought it was acceptable to flush tubes before confirming placement if aspirate was difficult to obtain Safe equipment In most trusts safe equipment appears to Are you confident that Nasogastric tubes have been introduced at the time of the procurement decisions used for feeding are NPSA 2011 alert (if it was not already in always include clinical radio-opaque use). But there were isolated cases when a advice on patient safety throughout their later decision to change suppliers for cost considerations? length and have effectiveness meant that non-compliant Are you confident clinical externally visible nasogastric tubes were re-introduced, and supply systems would length markings. pH this was not recognised until after a Never ‘block’ any accidental paper is CE marked Event had occurred. ordering of for use on human Other incident investigations found a noncompliant aspirate range of pH paper, not all CE marked, was alternatives?
APPENDIX 2 AREAS FOR SELF ASSESSMENT Main subject Heading Requirements/Standards Gap analysis RAG Rating Policy Are you confident local policies and protocols accurately reflect all the safety-critical requirements summarised in this resource Are you confident policies and protocols are clear and accessible to frontline staff? National safety guidance This needs to be referred to in any incident investigation In comparing what happened with ‘what should have happened’, investigation summaries almost never refer to NPSA alerts or actions required within them, and appear to rely on local policy or the investigators’ understanding of good practice. Some investigations showed an apparent lack of understanding by investigators of how nasogastric tube placement should be checked on x-ray, and one investigation report suggests the investigator thought it was acceptable to flush tubes before confirming placement if aspirate was difficult to obtain Are you confident that investigators refer to formal sources of guidance, such as Patient Safety Alerts or NICE guidance to set the standard on ‘what should have happened’ as part of any investigation? Safe equipment Nasogastric tubes used for feeding are radio-opaque throughout their length and have externally visible length markings. pH paper is CE marked for use on human aspirate In most trusts safe equipment appears to have been introduced at the time of the NPSA 2011 alert (if it was not already in use). But there were isolated cases when a later decision to change suppliers for cost effectiveness meant that non-compliant nasogastric tubes were re-introduced, and this was not recognised until after a Never Event had occurred. Other incident investigations found a range of pH paper, not all CE marked, was Are you confident that procurement decisions always include clinical advice on patient safety considerations? Are you confident clinical supply systems would ‘block’ any accidental ordering of noncompliant alternatives?