Patient safety prompts change in airways procedure

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

This 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:

  • Increased the risk of contamination and cross infection if the tubes were used for more than one patient.
  • Created more waste as only a small amount of the lubricant was needed for each procedure.

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 undertaken with the support of Clinical and Product Assurance (CaPA) and NHS England/Improvement. 

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Upcoming Events

Managing Deteriorating Conditions 2021

National Conference Centre Birmingham
19th April

Infection Prevention & Control Conference 2021

National Conference Centre Birmingham
20th - 21st April

BSG Annual Meeting 2021

SEC Glasgow, Glasgow, G3 8YW
19th - 21st May

EBME Expo 2021

Marshall Arena, Stadium MK, Milton Keynes Stadium Way West Milton Keynes MK1 1ST
30th June - 1st July

Central Sterilising Club 60th Anniversary Annual Scientific Meeting

Crowne Plaza, Bridge Foot, Stratford-upon-Avon, CV37 6YR
4th - 5th April