Policy responses and statements
- Name of organisation:
- National Patient Safety Agency
- Name of policy document:
- Preventing Wrong Route Errors with Oral/Enteral Medicines, Feeds and Flushes
- Deadline for response:
- 31 March 2006
Background: Oral/enteral liquid medicines and feeds are often administered to babies, young children and adults who have impaired ability to swallow solid dose forms. They may be administered by mouth or, when indicated, via a licensed feeding tube.
There have been published incident reports of death and harm in the UK and worldwide following wrong route errors when oral/enteral medicines, feeds and flushes have been administered intravenously in error.
The National Patient Safety Agency is undertaking a wide stakeholder consultation on recommendations intended to prevent wrong route errors with oral/enteral medicines, feeds and flushes. The NPSA plans to issue final recommendations to prevent wrong route errors in the NHS in England and Wales later in 2006. Comments and suggestions concerning this draft were requested.
COMMENTS ON
NATIONAL PATIENT SAFETY AGENCY
PATIENT SAFETY ALERT
PREVENTING WRONG ROUTE ERRORS WITH
ORAL/ENTERAL MEDICINES, FEEDS AND FLUSHES
Wide Stake Holder Consultation – Response Form
Please send complete form to oral-connectors@npsa.nhs.uk
Your contact details
Organisation Name: Royal College of Physicians of Edinburgh
Contact Name: Lesley Lockhart
Position: Team Leader, Fellowship Support Unit
Telephone: 0131-247 3608 Email: l.lockhart@rcpe.ac.uk
1) What are your views on the two main risks identified by the NPSA that contribute to the risk of wrong route errors with oral/enteral medicines feeds and flushes? Are there any risks that we have not identified or are inappropriately included?
The two main risks identified are clearly of a practical/mechanical nature. In addition, human error will still occur, and the usual concerns, distraction, multi-tasking, inadequate training will still pertain. On a further practical note, the current budgetary and ward stock practices of the NHS pose a considerable risk, as specialist oral/enteral syringes are rarely available; the cost both for supplies (particularly if devices are only used once), and training of staff should not be underestimated and may prove to be independent risks in their own right.
2) Will the recommendation that NHS organisations should only use oral, enteral or catheter tip syringes (that are not compatible with intravenous and other parenteral devices) reduce these risks?
Yes, this recommendation should reduce the risks of wrong route errors, but only if funded and implemented - see concerns at 1) above.
3) Will restricting the types of ports included in nasogastric and enteral feeding catheters through which medicines, feeds or flushes are to be administered, or which may be used for aspiration reduce the risk of wrong route errors?
Yes, if manufacturers can be persuaded not to use female luer ports or design new style ports then this can only be helpful, providing compatible devices for drug administration are available for use.
4) Will restricting the types of inline ports and terminal connectors in enteral administration and extension sets reduce the risk of wrong route errors?
Yes.
5) Will minimising the use of three way taps in oral/enteral feeding systems reduce the risk of wrong route errors?
Yes.
6) Will minimising the use of adaptors in oral/enteral feeding systems reduce the risk of wrong route errors?
Yes.
7) Will minimising the use of devices designed for uses other than enteral reduce the risk of wrong route errors?
Yes.
8) What are your views concerning the proposed local risk management measures when devices that do not meet the NPSA recommendations are not available or where the use of three way taps or adaptors is unavoidable?
If the new syringe system is widely introduced then such circumstances should be rare. The most common situation might be the emergency use of a urinary catheter to replace a displaced PEG tube, to prevent closure of the stoma. Procedures to replace the peg tube should be in place locally and followed - ideally the availability of trained staff within 24 hours. Administration through the catheter would need a catheter-tipped syringe which would meet recommendations … local protocols here already specify the use of oral/enteral syringes to draw up low volume medicines which can then be added to the catheter-tipped syringe for administration.
9) What are your views on the recommendation that all oral/enteral devices should be clearly labelled, employing effective colour and design to aid correct selection and use?
The use of colour coding is commended, for example the “BAXA” system. There may still be some difficulties in “drawing up” medicines and device design should take account of this.
10) Do NHS organisations already have procedures for the preparation and administration of oral/enteral medicines, feeds and flushes in their medicines and enteral feeding policies? Are these reflected in the organisation’s training programmes and competence assessments? What are your views on the NPSA recommendation on training and competence?
The BAPEN guidance has been used by some Drug and therapeutics committees locally in Scotland to prepare guidelines.
11) What are the barriers that may prevent the successful implementation of this guidance? Will any new risks be introduced by implementation?
The main barrier to implementation is the availability of supplies and training as mentioned above.
12) How could the presentation of the final patient safety alert be improved?
Most of the statements are of the “must not” category. If possible, a more positive tone should be adopted.
13) Do you have any other comments concerning the draft NPSA Safer Practice Alert?
No.
14) Do NHS organisations already conduct audits of oral/enteral administration including the type of medical devices used? How frequently do these audits take place? What are your views on the NPSA recommendations on audit?
Such incidents will be picked up in wider medication incident reporting, but the more detailed audit suggested, and frequency, would have enormous resource implications. The initial cost of new devices and training is likely to take priority.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[31 March 2006] |
