National Patient Safety Agency (NPSA) – a Dietitians guide OR The return of the syringe Ann...
-
Upload
luis-webster -
Category
Documents
-
view
220 -
download
2
Transcript of National Patient Safety Agency (NPSA) – a Dietitians guide OR The return of the syringe Ann...
National Patient Safety Agency(NPSA) – a Dietitians guide
OR‘The return of the syringe’
Ann AshworthNutrition Support Specialist Dietitian
Torbay HospitalTorquayTQ2 7AA
2nd August 2006
Aims
• Identify risks involved
• NPSA Alert
• Effect on practice
• Formulate an action plan
• Questions/discussion
Case study
• CVA patient
• Admitted PEG removal and supra-pubic catheter
• Perforation – laparotomy
• ICU - triple lumen line
• Clinical incident: Oral Verapamil given via central line
Identify risks
• With a partner try and list the number of connectors and ports in an Enteral Feeding System, from feed reservoir to patient
• connector = ‘thing that connects’ • anywhere the system can be accessed (not pump
insert)
• Identify if male/female luer connectors as appropriate.
Identify risks
• What is an– Oral syringe?– Enteral syringe?– Catheter tip syringe?– Luer syringe? (lock/slip?)
• See handout for NPSA draft glossary
NPSA Alert
• ‘Preventing wrong route errors with oral/enteral medicines, feeds and flushes’
• Patient safety alert ‘requires prompt action to address high risk safety problems’
NPSA Alert
• www.npsa.nhs.uk – health professionals current projects – Medication Practice – NPSA stakeholder consultation - preventing wrong route errors
• www.saferhealthcare.org.uk
NPSA Alert
• Only oral, enteral or catheter tip syringes…. must be used to administer oral/enteral medicines, feeds and flushes to patients
NPSA Alert
• Ports on nasogastric and enteral feeding tubes….must be male luer, catheter or other non-female luer in design
NPSA Alert
• Admin and extension sets must not contain any in-line female luer ports
• Use of three way taps not recommended
• Adaptors that convert syringes to connect with IV must not be used
NPSA Alert
• No final dates for publication – due in Autumn
• Use oral/enteral syringes in all clinical areas by 31st December 2006
• All other recommendations 30th September 2007
• e.g. NHS should not buy devices which do not comply
Effect on practice??
• No longer use IV (male luer) syringes or three way taps for medications/flushing
• Until side ports changed, meds/flushes have to be given via feeding tube
• Multiple breaks in system – microbiological issue?
Effect on practice??
• Design and sizes of syringes
• Patients/carers need consistent advice
• Trust policy on enteral feeding and/or single use syringes will need re-writing
Action plan – Risk assessment
• Read NPSA document
• Discuss with colleagues to determine which equipment/practice does not comply
– Form multidisciplinary group to write action plan (e.g. Chief Pharmacist, Nutrition nurses, Clinical Governance, Director of Nursing)
Summary
• Enteral feeding connectors
• Aware of risks
• Aware of Alert from NPSA and timeline
• Ideas for an action plan
• Questions?