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?