Factors Associated With Nasogastric Tube Placement-Related Complications in a Single Academic Medical Center.

IF 0.9 4区医学 Q4 HEALTH CARE SCIENCES & SERVICES

Journal for Healthcare Quality Pub Date : 2024-09-01 DOI:10.1097/JHQ.0000000000000448

Whitney Pickel, Elizabeth Talbott, Justine Abram, Richard Bernardi, DaWanda Forester, Joshua Hawkins, Jennifer Henry, Danielle Nesbitt, Candice Smith, Keith Gray

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引用次数: 0

Abstract

Objective: At our 710-bed academic medical center, nine (9) patients sustained injuries during nasogastric (NG) tube insertion attempts over a 16-month period (March 2021-July 2022). No injuries were reported during the comparable period before these events. This increase in reported events prompted an in-depth analysis to determine the root causes and implement a process improvement plan.

Methods: Root cause analysis (RCA) of these events failed to identify risk factors or actionable themes. The RCAs demonstrated wide variation in the number of insertion attempts and techniques.

Results: A standard process was created to provide team members with guidance for escalation when NG tube placement was difficult.

Conclusions: Although the complication rate for NG tube insertion was comparable with the criterion standard for large tertiary care institutions, we focused on minimizing risk and improving outcomes by creating a standard process for NG tube placement.

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单个学术医疗中心中与鼻胃管置入相关并发症有关的因素。

目的：在我们拥有 710 张病床的学术医疗中心，在 16 个月（2021 年 3 月至 2022 年 7 月）的时间里，有九（9）名患者在尝试插入鼻胃管（NG）时受伤。而在发生这些事件之前的可比时期内，未报告过任何伤害事件。报告事件的增加促使我们进行深入分析，以确定根本原因并实施流程改进计划：这些事件的根本原因分析 (RCA) 未能确定风险因素或可操作的主题。RCA显示插入尝试的次数和技术存在很大差异：结果：建立了一个标准流程，为团队成员提供指导，以便在 NG 管置入困难时进行升级：尽管 NG 管插入的并发症发生率与大型三级医疗机构的标准不相上下，但我们还是通过建立 NG 管置入的标准流程，将风险降至最低并改善了结果。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Journal for Healthcare Quality HEALTH CARE SCIENCES & SERVICES-

CiteScore

2.10

自引率

0.00%

发文量

期刊介绍： The Journal for Healthcare Quality (JHQ), a peer-reviewed journal, is an official publication of the National Association for Healthcare Quality. JHQ is a professional forum that continuously advances healthcare quality practice in diverse and changing environments, and is the first choice for creative and scientific solutions in the pursuit of healthcare quality. It has been selected for coverage in Thomson Reuter’s Science Citation Index Expanded, Social Sciences Citation Index®, and Current Contents®. The Journal publishes scholarly articles that are targeted to leaders of all healthcare settings, leveraging applied research and producing practical, timely and impactful evidence in healthcare system transformation. The journal covers topics such as: Quality Improvement • Patient Safety • Performance Measurement • Best Practices in Clinical and Operational Processes • Innovation • Leadership • Information Technology • Spreading Improvement • Sustaining Improvement • Cost Reduction • Payment Reform