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Patient safety prompts change in procedure

Posted on 7 January 2021

Trusts are being recommended to adopt new practices to protect the safety of patients who need tubes inserted in their airways, thanks to a risk analysis project run by NHS Supply Chain.

It is part of the important clinical work undertaken by NHS Supply Chain to ensure the safety of products to protect patients.

In September a National Patient Safety Alert was issued after it was found that silver discs which are used on lubricant tubes to keep them sterile could be a potential hazard if they entered the tube leading to a patient’s airway. The silver colour made them hard to spot.

The alert prompted a patient safety review by registered nurse Theresa Bowles from NHS Supply Chain: Rehabilitation, Disabled Services, Women’s Health and Associated Consumables, provided by Collaborative Procurement Partnership.

Her review also found the use of lubricant from tubes:

NHS trusts will now be encouraged to buy 5g lubricant sachets instead, which have coloured packaging. They are available via the NHS Supply Chain catalogue.

Theresa Bowles, Clinical Engagement and Implementation Manager for NHS Supply Chain, said: “This project is an example of how we as clinicians can work with our procurement colleagues to improve patient safety and achieve that without any additional cost to trusts.

“By making a relatively minor change to the way they operate NHS trusts can reduce the risk of small parts from lubricant tubes entering a patient’s airway.

“The sachets are coloured so they stand out more if any bits come off them and if more lubricant is needed then another sachet can be used. This has the bonus of reducing waste, with the environmental benefits that brings.”

NHS Supply Chain will be communicating the recommended new practice through various customer communications, including through their NHS Supply Chain Customer Relationship Managers.

The review has been done with the support of Clinical and Product Assurance (CaPA) and NHS England/Improvement.

Jo Gander, NHS Supply Chain’s Director of Clinical and Product Assurance (CaPA) said: “This project demonstrates how crucial NHS Supply Chain’s clinical work is to protect the safety of patients. I’d like to thank Theresa and the tower team for identifying the problem and making improvements.”