Eveleigh Mark, Law Robert, Pullyblank Anne, Bennett Joanne
University Hospitals Bristol.
Nurs Times. 2011;107(41):14-6.
The Department of Health recognises that feeding through a misplaced nasogastric feeding tube is largely preventable if appropriate steps are taken, and lists it as a never event. After one such never event at a trust, a team of senior clinical staff, senior nursing staff, radiographers, dietitians and medical educational staff were involved in tackling the causes of the problem. This article discusses the steps they took to change trust culture to make placing nasogastric feeding tubes a safer procedure.
卫生部认识到,如果采取适当措施,通过误置的鼻胃饲管进行喂食在很大程度上是可以预防的,并将其列为严重可避免事件。在一家信托机构发生了一起此类严重可避免事件后,一组资深临床工作人员、高级护理人员、放射技师、营养师和医学教育人员参与了问题原因的调查。本文讨论了他们为改变信托机构文化所采取的措施,以使鼻胃饲管置入成为一个更安全的操作流程。