NBT wins prestigious patient safety award

Tuesday, 15 March 2011

North Bristol NHS Trust won the Changing Culture category at the Patient Safety Awards 2011 for its work in changing the processes associated with the insertion of feeding tubes.

Changes have been across the Trust as a result of an investigation back in 2009 when a feeding tube was incorrectly inserted into a patient.

One of the key areas for concern was that the junior doctor who inserted the tube misinterpreted an X-ray, used to check on the position of the feeding tube, and carried out the procedure in the middle of the night when there was less support from more senior staff.

Since then a team led by Clinical Director Anne Pullyblank, Consultant Radiologist Rob Law and junior doctor Mark Everleigh looked at the reasons behind the mistake and a six-month audit of the procedure was carried out.

This found that the insertion of tubes in the night was actually relatively common and a decision was made to stop this practice with immediate effect for 18 months. Junior doctors were also stopped from carrying out the procedure during this time.

Following this an e-learning package was developed in order to fully train staff in the procedure which is followed by a test around the interpretation of X-rays for which they must achieve a 100 percent score to pass.

A sticker is now attached to patient notes to alert doctors if a colleague has attempted to inset a feeding tube and X-rays, to check on the position of feeding tubes, are now treated as a priority.

Anne Pullyblank said: “This is a real tangible example of the NHS learning from its mistakes and we were thrilled to be recognised with this award.”