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Chest drain insertion – improving patient safety Introduction Winter BTS December 2008 Nick Maskell

Chest drain insertion – improving patient safety Introduction Winter BTS December 2008 Nick Maskell. Courtesy of Fergus Gleeson. National Patient Safety Agency (NPSA). May 2008 NPSA received 12 reports of deaths related to chest drain insertion and 15 causes of severe harm (2005-2008)

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Chest drain insertion – improving patient safety Introduction Winter BTS December 2008 Nick Maskell

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  1. Chest drain insertion –improving patient safetyIntroductionWinter BTSDecember 2008Nick Maskell

  2. Courtesy of Fergus Gleeson

  3. National Patient Safety Agency (NPSA) • May 2008 • NPSA received 12 reports of deaths related to chest drain insertion and 15 causes of severe harm (2005-2008) • A substantial number of less severe incidents also reported indicating poor management • All but 1 - Seldinger type drains

  4. Immediate action – by 17th November • Chest drains only inserted by staff with relevant competencies • Ultrasound strongly advised • Clinical guidelines are followed and staff aware of risks • Identify lead for training • Written evidence of consent obtained from patients

  5. Because of risks from chest drain insertion – Clinical team should ask • Do I need to do this? • Does it need to be done as an emergency – can it wait? • Have I had enough training to feel confident to do this? • Am I familiar with the equipment? • Is US available, with trained staff, to position it safely?

  6. Common themes • Supervision of junior doctors – poor • Low level of experience of clinicians inserting chest drains • Failure to follow manufacture instructions • Poor site of insertion • Excessive insertion of dilator • Inadequate imaging • Lack of knowledge of guidelines

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