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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.

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Presentation on theme: "National Patient Safety Agency (NPSA) – a Dietitians guide OR The return of the syringe Ann Ashworth Nutrition Support Specialist Dietitian Torbay Hospital."— Presentation transcript:

1 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

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.

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

10 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

11 NPSA Alert – health professionals current projects – Medication Practice – NPSA stakeholder consultation - preventing wrong route errorswww.npsa.nhs.uk

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

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

14 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

15 NPSA Alert No final dates for publication – due in Autumn Use oral/enteral syringes in all clinical areas by 31 st December 2006 All other recommendations 30 th September 2007 e.g. NHS should not buy devices which do not comply

16 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?

17 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

18 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)

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


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