Radiographer Led Nasogastric Tube Position Check Pathway
Never events related to misplaced nasogastric tubes continue to occur across the NHS despite multiple prior alerts and local systems being implemented.
The Healthcare Safety Investigation Branch (HSIB) 2020 report into a never event related to a misplaced nasogastric tube highlighted radiographic interpretation as a critical area of weakness in the healthcare system leading to patient harm.
A collaborative group of professional bodies has created a radiographer-led pathway for adoption across the NHS as a system-wide preventative measure to reduce the number of nasogastric tube related never events that take place. Incorrect nasogastric tube placement risks administering nutrition or medications into the lungs rather than the stomach, leading to serious complications including pneumonia and death.
Radiographer empowerment and workforce training is a highly effective strategy to reduce nasogastric tube-related never events: radiographers can highlight misplaced nasogastric tubes and initiate actions to rectify this at the time they acquire the nasogastric tube X-ray. A national standardised competency-based safe nasogastric tube placement pathway and training programme has been created for radiographers by a multidisciplinary team to use their skills and knowledge to improve outcomes for patients needing nasogastric tubes.
The project team has developed an e-learning package that aims to develop and evaluate radiographers’ competence and confidence in identifying nasogastric tubes that are correctly placed, and those that are not, and to empower them to take corrective action as needed at the point at which they acquire the x-ray. This eliminates waiting times for misplaced tubes to be removed, and once a tube has been reinserted correctly, enables feeding or medication administration to commence without further delay.
We are seeking NHS sites to pilot this new pathway, through engagement with the e-learning materials and a commitment to changing practice on the ground. You will need to secure approval of the new pathway through local governance arrangements and participate in pre- and post-implementation audits. We’ll provide access to the training materials, template clinical governance documents and standard operating procedures, and the project team will be available for weekly drop-in mentoring advice. Lessons learned from the first phase of implementation will inform future rollout.
Radiologists are key to getting this pathway implemented at Trust level. If you are interested in using the Nasogastric Tube Position Check Pathway in your service , please liaise initially with your Clinical Director and contact [email protected].