Discovering Innovation at the Intersection of Undergraduate Medical Education, Human Factors, and Collaboration: The Development of a Nasogastric Tube Safety Pack

Abstract

Problem: Significant deficiencies exist in the knowledge and skills of medical students and residents around health care quality and safety. The theory and practice of quality and safety should be embedded into undergraduate medical practice so that health care professionals are capable of developing interventions and innovations to effectively anticipate and mitigate errors.

Approach: Since 2011, Leeds Medical School in the United Kingdom has used case study examples of nasogastric (NG) tube patient safety incidents within the undergraduate patient safety curriculum. In 2012, a medical undergraduate student approached a clinician with an innovative idea after undertaking an NG tubes root cause analysis case study. Simultaneously, a separate local project demonstrated low compliance (11.6%) with the United Kingdom's National Patient Safety Agency NG tubes guideline for use of the correct method to check tube position. These separate endeavors led to interdisciplinary collaboration between a medical student, health care professionals, researchers, and industry to develop the Initial Placement Nasogastric Tube Safety Pack.

Outcomes: Human factors engineering was used to inform pack design to allow guideline recommendations to be accessible and easy to follow. A timeline of product development, mapped against key human factors and medical device design principles used throughout the process, is presented. The safety pack has since been launched in five UK National Health Service (NHS) hospitals, and the pack has been introduced into health care professional staff training for NG tubes.

Next steps: A mixed-methods evaluation is currently under way in five NHS organizations.

Figure 1

Leeds Medical School spiral patient safety curriculum model. Based on a human factors framework, the Leeds Medical School undergraduate medicine curriculum enables students to link theory and the reality of practice. Abbreviation: NPSA indicates the United Kingdom’s National Patient Safety Agency.

Figure 2

A version of the traffic light prompt card used in the Initial Placement Nasogastric Tube Safety Pack (Supplement Digital Appendix 2 at http://links.lww.com/ACADMED/A315) developed at Leeds Medical School, 2012. The traffic light prompt card system makes guideline recommendations accessible, concise, and easy to follow. The green traffic light instructs the user to use pH aspirate check as a first-line method for checking NG tube position. The amber traffic light demonstrates what to do if unable to obtain an aspirate. The red traffic light shows that the tube is not safe to feed if no aspirate is obtained or if the pH value is greater than that agreed by local policy, prompting a request for X-ray. Confirmation on method according to NPSA/2011/PSA002. Abbreviations: NG indicates nasogastric; NEX, nose, earlobe and xyphoid; NPSA, the United Kingdom’s National Patient Safety Agency. ^aSee Supplemental Digital Appendix 2, http://links.lww.com/ACADMED/A315, for diagram. ^bNPSA Alert NPSA/2011/PSA002 states pH 5 or less is safe to feed; pH value between 5 and 5.5 indicates a check is required by a second competent person.⁴