139 “Never Event, Never Again” - a Closed Loop Audit on the Documentation of Nasogastric Tube Position Following X-Ray Confirmation

Abstract

Abstract Aim Nasogastric feeding is common among ENT patients with dysphagia. CXRs are performed to confirm tube position before feeding. However, communication failure from poor documentation potentially leads to feeding through a misplaced tube into the lungs which is a "Never Event". This audit aims to reduce risk of patient harm by encouraging the use of nasogastric tube documentation sticker on clinical notes in Royal Victoria Hospital ENT ward. Method An initial study was conducted in June 2022 evaluating the quality of documentation of NGT position following CXR. Subsequently, several interventions were implemented including teaching doctors on utilising the documentation sticker that comes with each NGT pack, placing posters on the ward and reminding the nursing staff to check the documentation before starting feed. Further re-audit was carried out in August 2022 post-intervention. Results 58 CXRs were performed. Use of the documentation sticker rose from 42.1% to 85%. This led to verification of patient identity increasing from 39.5% to 100% and confirmation that the x-ray was most recent for the patient from 44.7% to 100%. 85% of the x-rays had time and date verified compared to 34.2% previously. Documentation of the position of NGT and instructions for feeding improved from 63.1% to 75% and 65.8% to 75% respectively. Record of the staff who confirmed tube position increased from 60.5% to 75%. Conclusions This audit demonstrated an increased use of the documentation sticker resulting in improvements in confirmation and documentation of NGT position. These positive changes reduce risks of significant patient harm thereby improving patient safety.