June 3, 2008
UK Advisory on Chest Tube Insertion
The National Patient Safety Agency of the UK NHS just released a rapid response report on the risks of chest drain insertion along with supporting information. The report was prompted by reports of 12 deaths and 15 cases of serious harm over a three year period. These included cases where heart, lungs, major vessels, trachea, phrenic nerve or liver were punctured with consequent hemorrhage or otherwise injured.
Also, over the years that the NYPORTS system in New York has been tracking serious incidents, chest tube insertion has been one of the most common procedures implicated in “wrong site” incidents. The institution’s timeout/verification/safe site protocol should be followed during chest tube insertion just as if you were performing a procedure in the operating room.
The UK report recommends the clinical team always ask the following questions when contemplating inserting a chest drain:
They provide a search of the literature to identify many of the factors contributing to untoward outcomes from chest tube insertion. Lack of appropriate training and supervision, unfamiliarity with equipment, and lack of understanding of anatomical considerations were common contributing factors.
AHRQ has actually funded production of a DVD that uses video excerpts of 50 actual chest tube insertions and uses a nemonic to help illustrate some of the more common problems:
The DVD is available through the AHRQ website.
Many hospitals are seeing the development of “proceduralists” to handle procedures which are prone to risk, particularly when done by less experienced staff. Particularly in the era where CMS and other third party payors are beginning to withhold payment in cases with preventable complications, development of proceduralist programs is looking more and more cost effective.
UK NPSA Rapid Response Report: Risks of chest drain insertion. May 15, 2008 http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=11636
UK NPSA. Supporting Information.Rapid Response Report: Risks of chest drain insertion. Reference NPSA/2008/RRR03. Issued: May 2008
Problems and Prevention: Chest Tube Insertion. Patient Safety: Findings in Action. AHRQ Publication
No. 06-P024, September 2006. Agency for Healthcare Research and Quality, Rockville, MD.
Landro L. To Reduce Risks, Hospitals Enlist 'Proceduralists'. Wall Street Journal
July 11, 2007