EP.TH.26Identification of Common Themes from Never Events Data Published by NHS England

Background Never events (NEs) are serious clinical incidents that cause potentially avoidable harm and impose a significant financial burden on healthcare systems. The purpose of this study was to identify common never events. Methods We analysed the NHS England NE data from 2012 to 2020 to identify common never events category and themes. Results We identified 51 common NE themes in 4 main categories out of a total of 3247 NE reported during this period. Wrong-site surgery was the most common category (n = 1307;40.25%)) followed by retained foreign objects (n = 901;27.75%); wrong implant or prosthesis (n = 425;13.09%); and non-surgical/infrequent ones (n = 614;18.9%). Wrong-side and wrong tooth removal were the most common wrong-site NE accounting for 300 (22.95%) and 263 (20.12%) incidents, respectively. There were 197 (15%) wrong-site blocks, 125 (9.56%) wrong procedures, and 96 (7.3%) wrong skin lesions excised. Vaginal swabs were the most commonly retained items (276;30.63%) followed by surgical swabs (164;18.20%) and guidewires (152;16.87%). There were 67 (7.44%) incidents of retained parts of instruments and 48 (5.33%) retained instruments. Wrong intraocular lenses (165;38.82%) were the most common wrong implants followed by wrong hip prostheses (n = 94;22.11%) and wrong knees (n = 91;21.41%). Non-surgical events accounted for 18.9% (n = 614) of the total incidents. Misplaced naso-or oro-gastric tubes (n = 178;29%) and wrong-route administration of medications were the most common events in this category (n = 111;18%), followed by unintentional connection of a patient requiring oxygen to an air flow-meter (n = 93;15%). Conclusion This paper identifies common NE categories and themes. Awareness of these might help reduce their incidence.

Influence of Homogenization in the Physicochemical Quality of Human Milk and Fat Retention in Gastric Tubes

Background: The retention of human milk nutrients in gastric tubes used to feed premature infants is a challenge to be overcome. Research Aims: To evaluate (1) the performance of six homogenizers (mixing processor, piston valve, ultrasonic bath, ultraturrax, stirring mixer, and ultrasound probe) for the fat retention reduction in gastric tubes; (2) the influence of the best homogenization conditions on the fatty acid and protein profiles of human milk; and (3) the cost/benefit ratio for the inclusion of homogenization as a new step in human milk processing. Methods: The influence of different levels and times of homogenization on reducing fat retention of human milk in probes was evaluated in this comparative prospective cross-sectional study. After homogenization, human milk flowed through a gavage and infusion pump apparatus used for feeding. Fat content was quantified before and after feeding. The techniques that reduced fat globule sizes and/or promoted a lower percentage of fat holding were evaluated for efficiency, variations in the fatty acid and protein profiles, and energy density and operating costs. Results: Homogenization led to a reduction in fat retention in feeding probes. The mixer processor and the ultrasound probe reduced fat retention by 99.23% (SD = 0.07) and 99.95% (SD = 0.02), respectively, and did not negatively influence fatty acid and protein profiles. The mixer processor demonstrated low energy density and low cost for human milk processing. Conclusion: Homogenization promoted reduced fat retention in the feed probe and could help maintain fat nutrients of human milk during enteral feeding.

Comparison of Using Cold Versus Regular Temperature Tube on Successful Nasogastric Intubation for Patients in Toxicology Emergency Department: a Randomized Clinical Trial

Introduction: In view of the contradictory results for the use of cold tubes for the purpose of enhancing nasogastric tube insertion success there is a pressing need for further research in this area. This study aimed to determine the effect of using cold versus regular temperature nasogastric tube on successful nasogastric tube insertion for patients referring to toxicology emergency department. Methods: This study is a clinical trial with two groups design of 65 patients admitted to toxicology emergency department who were divided into two groups by random allocation. Nasogastric tubes used in the intervention group had been stored in a refrigerator at 2°-8° C while the ones employed in the control group had been maintained at the room temperature of 22-28° C. Nasogastric tube insertions in both groups were done by the investigator according to standard methods. The data were analyzed using SPSS ver. 13. Results: The placement of nasogastric tube was done in the first attempt with 27 (%84.4) of the subjects in the control group and 33 (%100.0) in the intervention group. The chi-square test results showed that the frequency of the number of attempts for gastric intubation in subjects between the two groups was statistically significant. Conclusion: Cooling gastric tubes reduces the time required for nasogastric intubation. Thus, it is suggested that the gastric tubes be cooled before the application of the procedure so as to reduce complications, increase patient comfort and save nurses time.

Are Mangiferin and Mangiferin-Containing Plant Extracts Helpful for Iron-Loaded Transfusion-Dependent and Non-Transfusion-Dependent Thalassaemia Patients?

Treatment of iron overload in thalassaemia is still a great burden for patients, their families and the health care system in developing countries like Indonesia, because of expensiveness and unwanted side effects of chemical iron-chelating therapeutics. This animal study investigates an extract from the leaves of Mangifera foedica L (EMF) and its major active compound, mangiferin, for chelating and antioxidant treatment of iron overload. Sixty rats were randomly divided into 10 groups: control, iron overload (IO), and IO with mangiferin doses between 50 and 200 mg/g BW or 2390 mg of EMF, applied via gastric tubes. For comparison, deferiprone (DFP) was used. Iron overload was induced by intraperitoneal iron dextran resembling two models, transfusion-dependent (TDT) or nontransfusion-dependent thalassaemia (NTDT). Increasing oral doses of mangiferin and EMF did not result in higher mangiferin plasma levels; however, mangiferin administered for four weeks roughly doubled blood levels compared to two weeks. In the TDT model, mangiferin significantly lowered ferritin levels by 21% and plasma iron levels by 60% (EMF by 50%), almost like DFP (by 70%) and increased iron excretion 6-fold via urine (DFP 15-fold, EMF 2-fold). In the NTDT model mangiferin and EMF decreased ferritin levels significantly by about 30%, without significantly decreasing excess plasma iron. Mangiferin increased iron excretion via urine 4-fold (EMF 2-fold) and tended to diminish Fe accumulation in liver and heart. Iron chelating effects of EMF were weaker than of mangiferin, but its in vivo antioxidant activity was stronger. In vitro, both mangiferin and the mangiferin/FeIII complex are potent superoxide radical scavengers, the iron complex being superior.

Percutaneous Transesophageal Gastric Tubes: Indications, Technique, Safety, Efficacy, and Management

Percutaneous transesophageal gastric (PTEG) tube placement is an alternative method of gastric access for feeding or decompression in patients with contraindications to conventional gastrostomy tube placement such as peritoneal carcinomatosis, gastric wall tumors, ascites, or intervening organs. PTEG tube placement is safe with a high technical success rate and it can be placed with supplies available in most interventional radiology departments using ultrasound and fluoroscopic guidance. PTEG tubes are highly efficacious at reducing symptoms in patients with malignant bowel obstruction as an alternative to long-term nasogastric decompression.

Cricoid Pressure Controversies

Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure–associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure–related research are also discussed.

Treatment for early postoperative esophageal fistula complicated with anterior cervical surgery

Object: To investigate the efficacy of debridement, open drainage, and early feeding to treat early esophageal fistula complicated with anterior cervical surgery. Methods: Retrospective analysis was conducted on data from 3154 patients who had undergone anterior cervical surgeries for cervical vertebra diseases between January 2006 and January 2013, in which eight patients had esophageal fistula with five males and three females. Four patients had cervical spinal injuries and four patients had cervical spondylosis. All of whom had postoperative esophageal fistulas and underwent debridement and drainage. The wounds were left open for natural drainage. No drainage devices were placed in surgical sites, and no gastric tubes were placed after surgeries. Such normal food as rice balls but not liquid or semiliquid diet was recommended. Local pressurization was conducted with fists during feeding to prevent food overflowing from orificium fistulae. Results: Healed esophageal fistulas were achieved in all of the patients after 1–2 weeks treatment. There weren’t recurrent esophageal fistulas and delayed infection found during 2–5 years follow-up. Good swallowing functions and stable cervical vertebrae were achieved in all of the patients. The satisfactory therapeutic effects were achieved in patients with previous neck diseases. Frankel classifications were increased by 1–2 grades in patients with cervical spinal injuries. JOA scores were increased from 9.5 before surgery to 15.5 after surgery in patients with cervical vertebra diseases. Conclusions: Early postoperative esophageal fistula complication after anterior cervical surgery can successfully be treated by debridement, drainage without gastric tube, and with early oral postoperative feeding but without fluids.