NG tubes case study of identifying a target behaviour

It was decided that the misplacement of nasograstic (NG) tubes would be the main focus of this project.
An implementation team was set up and the NG tube alert was read in detail. The alert was found to
contain 17 guidelines in total, of which 10 were relevant to health care professionals, and 7 for
management. A number of behaviours were found to be related to this procedure, for example:
Making the correct decision to insert a NG tube
Using pH paper to check placement of the NG tubes
Sending the patient for an x-ray to check placement
Interpreting the x-ray correctly
The guideline indicated that the main cause of harm was found to be due to the misinterpretation of xray, thus leading the team to believe it was a case of lack of training on interpreting x-rays. However
once the team had read the surrounding literature and conducted an audit, it became apparent that pH
was being checked in very few cases, despite guidelines stating pH should be used a first line method for
checking placement of NG tubes. For example, in hospital one, pH was tested in only 20% of the cases
and in hospital 2 and 3 only 14% and 12% of cases. This led to further discussions with health care
professionals in order to define and agree on a specific problem behaviour that required addressing.
Discussions enabled the implementation team to establish that if pH was tested more often, this would
reduce the risk of misinterpretation (as less x-rays would be requested following successful pH checks),
provide more time for the radiology department to conduct other x rays, and importantly reduce the
risk of the tube becoming dislodged (as the patient would not need to be transported around the
hospital). The team came to the conclusion that target behaviour was whether pH was being tested as a
first line method for establishing the placement of the NG tube.
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