Enhancing patient safety during feeding-tube insertion: A review of more than 2000 insertions

Journal of Parenteral and Enteral Nutrition

Volumn 30, Issue 5, 2006, Pages 440-445

  Sorokin, Rachel ^a,b   Gottlieb, Jonathan E ^a  

^a THOMAS JEFFERSON UNIVERSITY   (United States)

^b Second Floor ^*  (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CLINICAL TRIAL; DIGESTIVE TRACT INTUBATION; ENTERIC FEEDING; HEALTH CARE QUALITY; HUMAN; INSTRUMENTATION; META ANALYSIS; METHODOLOGY; PATIENT CARE; RETROSPECTIVE STUDY; SAFETY; STANDARD; TREATMENT OUTCOME;

ENTERAL NUTRITION; HUMANS; INTUBATION, GASTROINTESTINAL; PATIENT CARE; QUALITY ASSURANCE, HEALTH CARE; RETROSPECTIVE STUDIES; SAFETY; TREATMENT OUTCOME;

EID: 33846689474     PISSN: 01486071     EISSN: None     Source Type: Journal    
DOI: 10.1177/0148607106030005440     Document Type: Article

References (27)

1. Leape LL. Error in medicine. JAMA. 1994;272:1851-1857.
2. Joint Commission on Accreditation of Health Care Organizations. An introduction to FMEA. Using failure mode effects analysis to meet JCAHO's proactive risk assessment requirement. Failure modes effect analysis. Health Devices. 2002;31:223-226.
3. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293:2384-2390.
4. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
5. Pauker SG, Zane EM, Salem DN. Creating a safer health care system: finding the constraint. JAMA. 2005;294:2906-2908.
6. Deming WE. Quality, Production and Competitive Position. Cambridge, MA: MIT Center for Advanced Engineering Study; 1982.
7. Batalden PB, Stoltz PK. A framework for the continual improvement of health care: building and applying professional and improvement knowledge to test changes in daily work. Jt Comm J Qual Improv. 1993;19:424-447.
8. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320:53-56.
9. McWey RE, Curry NS, Schabel SI, Reines HD. Complications of nasoenteric feeding tubes. Am J Surg. 1988;155:253-257.
10. Ghahremani GG, Gould RJ. Nasoenteric feeding tubes: radiographic detection of complications. Dig Dis Sci. 1986;31:574-585.
11. Harris MR, Huseby JS. Pulmonary complications from nasoen-teral feeding tube insertion in an intensive care unit: incidence and prevention. Crit Care Med. 1989;17:917-919.
12. Hendry PJ, Akyurekli Y, Mclntyre R, Quarrington A, Keon WJ. Bronchopleural complications of nasogastric feeding tubes. Crit Care Med. 1986;14:892-894.
13. Mardenstein EL, Simmons RL, Ochoa JB. Patient safety: effect of institutional protocols on adverse events related to the feeding tube placement in the critically ill. J Am Coll Surg. 2004;199: 39-50.
14. Roubenoff R, Ravich WJ. Pneumothorax due to nasogastric feeding tubes: report of four cases, review of the literature, and recommendations for prevention. Arch Intern Med. 1989; 149: 184-188.
15. Scholten DJ, Wood TL, Thompson DR. Pneumothorax from nasoenteric feeding tube insertion: a report of five cases. Am Surg. 1986;52:381-385.
16. Rassias AJ, Ball PA, Corwin HL. A prospective study of tra-cheopulmonary complications associated with the placement of nanwv-bore enteral feeding tubes. Crit Care Forum. 1998;2:25-29. Available at: http://www. pubmedcentral.nih.gov/articlerender. fcgi?artid=28998. Accessed June 30, 2006.
17. Bankier AA, Weismayr MN, Henk C, et al. Radiographic detection of intrabronchial malpositions of nasogastric tubes and subsequent complications in intensive care unit patients. Intensive Care Med. 1997;23:406-410.
18. Apkon M, Leonard J, Probst L, DeLizio L, Vitale R. Design a safer approach to intravenous drug infusions: failure mode effects analysis. Qual Saf Health Care. 2004;13:265-271.
19. rd ed. New York, NY: John Wiley & Sons, Inc; 1997.
20. Benneyan JC. Number-between g-type statistical quality control charts for monitoring adverse events. Health Care Manag Sci. 2001;4:305-318.
21. Odocha O, Lowery RC, Mezghebe HM, Siram SM, Warner OG. Tracheopleuropulmonary injuries following enteral tube insertion. J Natl Med Assoc. 1989;81:275-281.
22. Jackson RH, Payne DK, Bacon BR. Esophageal perforation due to nasogastric intubation. Am J Gastroenterol. 1990;85:439-442.
23. Powers J, Chance R, Bortenschlager L, et al. Bedside placement of small bore feeding tubes in the intensive care unit. Crit Care Nurse. 2003;23:17-24.
24. Welsh CH, Perdot R, Anderson RJ. Use of morning report to enhance adverse event detection. J Gen Intern Med. 1996; 11: 454-460.
25. Cullen DJ, Bates DW, Small CD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21:548-552.
26. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study 1. N Engl J Med. 1991;324:370-376.
27. Steel K, Gertman PM, Crescenzi C, Anderson J. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304:638-642.