National patient safety agency npsa a dietitians guide or the return of the syringe
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National Patient Safety Agency (NPSA) – a Dietitians guide OR ‘The return of the syringe’. Ann Ashworth Nutrition Support Specialist Dietitian Torbay Hospital Torquay TQ2 7AA 2 nd August 2006. Aims . Identify risks involved NPSA Alert Effect on practice Formulate an action plan

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National Patient Safety Agency(NPSA) – a Dietitians guideOR‘The return of the syringe’

Ann Ashworth

Nutrition Support Specialist Dietitian

Torbay Hospital

Torquay

TQ2 7AA

2nd August 2006


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Aims

  • Identify risks involved

  • NPSA Alert

  • Effect on practice

  • Formulate an action plan

  • Questions/discussion


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Case study

  • CVA patient

  • Admitted PEG removal and supra-pubic catheter

  • Perforation – laparotomy

  • ICU - triple lumen line

  • Clinical incident: Oral Verapamil given via central line


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Identify risks

  • With a partner try and list the number of connectors and ports in an Enteral Feeding System, from feed reservoir to patient

    • connector = ‘thing that connects’

    • anywhere the system can be accessed (not pump insert)

  • Identify if male/female luer connectors as appropriate.


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    Identify risks

    • What is an

      • Oral syringe?

      • Enteral syringe?

      • Catheter tip syringe?

      • Luer syringe? (lock/slip?)

    • See handout for NPSA draft glossary


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    NPSA Alert

    • ‘Preventing wrong route errors with oral/enteral medicines, feeds and flushes’

    • Patient safety alert ‘requires prompt action to address high risk safety problems’


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    NPSA Alert

    • www.npsa.nhs.uk – health professionals current projects – Medication Practice – NPSA stakeholder consultation - preventing wrong route errors

    • www.saferhealthcare.org.uk


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    NPSA Alert

    • Only oral, enteral or catheter tip syringes…. must be used to administer oral/enteral medicines, feeds and flushes to patients


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    NPSA Alert

    • Ports on nasogastric and enteral feeding tubes….must be male luer, catheter or other non-female luer in design


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    NPSA Alert

    • Admin and extension sets must not contain any in-line female luer ports

    • Use of three way taps not recommended

    • Adaptors that convert syringes to connect with IV must not be used


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    NPSA Alert

    • No final dates for publication – due in Autumn

    • Use oral/enteral syringes in all clinical areas by 31st December 2006

    • All other recommendations 30th September 2007

    • e.g. NHS should not buy devices which do not comply


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    Effect on practice??

    • No longer use IV (male luer) syringes or three way taps for medications/flushing

    • Until side ports changed, meds/flushes have to be given via feeding tube

    • Multiple breaks in system – microbiological issue?


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    Effect on practice??

    • Design and sizes of syringes

    • Patients/carers need consistent advice

    • Trust policy on enteral feeding and/or single use syringes will need re-writing


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    Action plan – Risk assessment

    • Read NPSA document

    • Discuss with colleagues to determine which equipment/practice does not comply

      • Form multidisciplinary group to write action plan (e.g. Chief Pharmacist, Nutrition nurses, Clinical Governance, Director of Nursing)


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    Summary

    • Enteral feeding connectors

    • Aware of risks

    • Aware of Alert from NPSA and timeline

    • Ideas for an action plan

    • Questions?