Roe G, Lambie H, Hood A, Tolan D
Department of Radiology, St James's University Hospital, Leeds Teaching Hospitals Trust, Beckett Street, Leeds, LS9 7TF, UK.
Radiography (Lond). 2019 Aug;25(3):235-240. doi: 10.1016/j.radi.2019.02.002. Epub 2019 Feb 19.
Ascertain if a new practice development designed to reduce 'never events' from feeding through misplaced nasogastric tubes (NGT) in a large teaching hospital Trust was acceptable to a large radiography workforce.
Despite National Patient Safety Agency guidance advising on safe practice for confirming position of NGTs a number of 'never events' still occur nationally due to misinterpretation of the check X-ray. A new practice development for radiographers included providing an immediate comment and removal of misplaced NGTs at the time of the check X-ray examination. Success of the new system was partly assessed using qualitative and quantitative measures of radiographer opinion of the training and different aspects of the system.
There was a significant improvement in radiographers' level of confidence in image interpretation after training (58/98 positive responses before, 89/98 positive after training) and after five months of experience at undertaking the role (96/98 positive) (p < 0.01). There was increased confidence in NGT removal post training and with five months of experience (16/95 positive before training, 67/96 positive after and 81/95 positive with five months of experience). 97/98 (99%) of radiographers agreed the new system benefits patients, 93/98 (95%) believed it a positive step for the radiography profession.
Evaluation of this new practice development has shown it was embraced by radiographers and is a workable and potentially cost-effective solution in addressing real time image interpretation issues that were evident from previous 'never events'. Large scale implementation of this system across the NHS Radiography workforce should be considered.
确定一家大型教学医院信托机构中旨在减少因鼻胃管(NGT)放置错误导致的“零失误事件”的新实践发展是否为广大放射技师群体所接受。
尽管国家患者安全机构已就确认鼻胃管位置的安全操作提供了指导,但由于对检查X光片的误判,全国仍有一些“零失误事件”发生。针对放射技师的一项新实践发展包括在检查X光时立即给出意见并移除放置错误的鼻胃管。新系统的成功部分通过对放射技师对培训及系统不同方面的意见进行定性和定量评估来衡量。
培训后,放射技师在图像解读方面的信心水平有显著提高(培训前98人中有58人给出积极反馈,培训后98人中有89人给出积极反馈),在承担该职责五个月后信心进一步增强(98人中有96人给出积极反馈)(p<0.01)。培训后及有五个月经验后,移除鼻胃管的信心增强(培训前95人中有16人给出积极反馈,培训后96人中有67人给出积极反馈,有五个月经验后95人中有81人给出积极反馈)。98名放射技师中有97人(99%)同意新系统对患者有益,98名放射技师中有93人(95%)认为这对放射技师职业来说是积极的一步。
对这一新实践发展的评估表明,它受到了放射技师的欢迎,是解决先前“零失误事件”中明显存在的实时图像解读问题的可行且可能具有成本效益的解决方案。应考虑在英国国家医疗服务体系(NHS)放射技师群体中大规模实施该系统。