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

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 guide OR ‘The return of the syringe’

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  1. 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

  2. Aims • Identify risks involved • NPSA Alert • Effect on practice • Formulate an action plan • Questions/discussion

  3. 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

  4. 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.

  5. Identify risks • What is an • Oral syringe? • Enteral syringe? • Catheter tip syringe? • Luer syringe? (lock/slip?) • See handout for NPSA draft glossary

  6. 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’

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

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

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

  10. 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

  11. 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

  12. 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?

  13. 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

  14. 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)

  15. Summary • Enteral feeding connectors • Aware of risks • Aware of Alert from NPSA and timeline • Ideas for an action plan • Questions?

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