Authors (including presenting author) :
Chan YH (1)(2), Cheung WM (1), Wong LG (1)
Affiliation :
(1) Patient Safety and Risk Management Team, Head Office Quality and Safety Department (2) Department of Medicine and Geriatrics, Princess Margaret Hospital/ Quality and Safety Department, Kowloon West Cluster
Introduction :
An adverse incident happened on 9 October 2024 involving misinterpretation of Chest X-ray (CXR) finding after Nasogastric (NG) tube insertion, feeding was commenced on an incorrectly placed NG tube, leading to serious consequences. There was another similar incident happened on June 2024. These captured media interest. A rapid response to the incident, as well as immediate boost up knowledge and skills for our interns for this skill, is desperately needed.
Objectives :
1. To foster a rapid response to incident through multi-disciplinary collaboration
2. To develop an e-Learning module to train interns on essential skills about CXR interpretation after NG tube insertion
Methodology :
NHS model of CXR training to junior doctors about interpretation on NG tube position was taken as reference[1,2]. A simple guide to interpret CXR was sent to all staff by email soon after the incident. (Figure 1) There was also refinement of investigation ordering module in Clinical Management System (CMS), with the introduction of specific “NG tube” view into CXR requests, with the view to reduce perceptual errors in interpreting CXR. (Figure 2) With collaboration with staff development and communication team of Human Resources Department as well as Medical Grade Unit, an e-Learning module to train interns on CXR interpretation after NG tube is developed. A learning video is provided to interns for reference. Abnormal and normal CXRs after NG tube insertion was retrieved from previous Adverse incidents reporting system (AIRS) reports, local Q&S units and radiology departments. Interns have to answer 10 true-or-false questions about CXR positioning. A competency score is defined as 100% score attained. Those unable to attain 100% are required to repeat the test in second round at 1 week later. Repeated failure would require counselling and direct supervision under intern supervisors to complete the test. (Figure 3)
Result & Outcome :
Total 529 interns were working in Hospital Authority (HA) during the captioned period. 95% have completed the test during the first round. 96.4% of candidates can attain 100% marks in either first or second round of assessment. 19 interns would need further education from department intern coordinators and all of them have completed re-training and assessment by 1 November 2024. After the assessment, the test is further refined to a multiple-choice format to tailor to real-life situation and decision making. It is further rolled out to the junior doctors and future batches of interns.
