From Pitfalls to Protocols: Advancing Patient Safety in Enteral Tube Management

Introduction: Standardization of small and large-bore enteral tube practices can reduce variability and exposure to potential harm. A quality improvement (QI) project at a midwestern 8-hospital healthcare organization aimed to reduce risk of patient harm by implementing best practices through order set and policy updates, supply standardization and staff education.


Methods: Patient safety events related to enteral tubes were reviewed from a 40-month period prior to implementation and 9-month following to evaluate potential areas for improvement. The events were either addressed through education or practice considerations. Education opportunities were collectively implemented into e-learning modules. Practice needs were addressed with interdisciplinary stakeholders through patient safety huddles, committees, and workgroups to identify solutions to system barriers or inefficiencies. Best practices from literature and current processes were evaluated and addressed in orders, assessments, and verification of tube placements. The QI project prioritized an efficient and safe process for staff entering orders, receiving orders, and carrying out interventions.


Results: A total of 151 patient safety events were reviewed pre-implementation, and 42 post-implementation. Of the 151 initial events, 122 (81%) were classified as educational opportunities, like tube dislodgement, delayed interventions, improper nasal bridle placement, and missed orders. Other issues were related to practice, such as wrong tube placed, missing orders, lung placement, inconsistent documentation, and delayed x-ray verification. After implementation, 37 of 42 events were issues already addressed by the project and were reinforced with staff, and 5 were device-related and outside its scope. Two system order sets replaced 6 local order sets, 6 system documents replaced 12 hospital documents, documentation was streamlined to reduce charting inconsistencies, and 6 educational modules were developed for nursing staff.


Conclusions: Staff-reported patient safety events helped develop a cohesive best practice approach to enteral tube insertion and care in a large healthcare organization. By standardizing processes and intentionally addressing sources of risk, the updated approach to enteral tube management helped avoid patient harm.