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National Patient Safety Agency
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National Patient Safety Agency warns of risks associated with chest drains

20 May 2008

 

The National Patient Safety Agency (NPSA) has alerted the NHS to the risks associated with inserting chest drains, commonly used on patients with chest trauma, collapsed lungs, or after surgery, to remove air and fluids.

 

The NPSA is warning NHS organisations that the drainage tubes should only be inserted by trained staff with relevant competencies and adequate supervision. Due to the risk of damaging internal organs through poor positioning, the NPSA strongly supports the use of ultrasound when positioning a drain.

 

The guidance follows reports of 12 deaths and 15 incidents of serious harm following the medical procedure over three years from January 2005 to March 2008, with several other less severe cases likely to have gone unreported.

 

Dr Kevin Cleary, Medical Director of the NPSA says: “This can be a technically difficult procedure and we have evidence that patients are being harmed, including twelve deaths reported to us in recent months.  Following best practice, including use of ultrasound to insert chest drains, will reduce harm.  Most of all, this needs to be recognised by staff as a high risk procedure.”

 

Nick Maskell, Consultant Respiratory Physician at North Bristol NHS Trust and Chairman, Pleural Disease Guidelines Group, British Thoracic Society says: “This warning to the service on the risks of inserting chest drains is very welcome.  The British Thoracic Society is producing more detailed guidelines – but as a chest physician, I know that some immediate steps can be taken now to make this practice safer.”

 

The NPSA also advises that where practicable patients will be required to provide written consent prior to the procedure.

 

The Rapid Response Report: Risks of Chest Drain Insertion - Reference NPSA/2008/RRR003 and supporting information can be found here.

 


 

 

Notes for editors:

 

  1. Media enquiries to the NPSA’s communications team: Paul Cooney on 020 7927 9351 / paul.cooney@npsa.nhs.uk or Nick Rigg on 0207 927 9362 / nick.rigg@npsa.nhs.uk
  2. The National Patient Safety Agency (NPSA) helps the NHS learn from its mistakes so that it can improve patient safety. It does this by collecting reports on errors and other things that go wrong in healthcare so that it can recognise national trends and introduce practical ways of preventing problems. It does not investigate individual cases or complaints, but it does listen to public concerns and uses what is said to improve safety.
  3. The Medicines and Healthcare Products Regulatory Agency (MHRA) have released reports of nine incidents since 2003, all but one relating to the use of Seldinger type drains, which is now the most commonly used technique.
  4. The British Thoracic Society produced guidelines in 2003. These are currently being reviewed and will be updated by 2009. This may include e-learning modules and other practical guidance to improve chest drain insertion technique.