Discovering innovation at the intersection of undergraduate medical education, human factors, and collaboration

The development of a nasogastric tube safety pack

Natalie Taylor*, Thomas Bamford, Cornelia Haindl, Alison Cracknell

*Corresponding author for this work

Research output: Contribution to journalArticle

1 Citation (Scopus)
10 Downloads (Pure)


Problem Significant deficiencies exist in the knowledge and skills of medical students and residents around health care quality and safety. The theory and practice of quality and safety should be embedded into undergraduate medical practice so that health care professionals are capable of developing interventions and innovations to effectively anticipate and mitigate errors. Approach Since 2011, Leeds Medical School in the United Kingdom has used case study examples of nasogastric (NG) tube patient safety incidents within the undergraduate patient safety curriculum. In 2012, a medical undergraduate student approached a clinician with an innovative idea after undertaking an NG tubes root cause analysis case study. Simultaneously, a separate local project demonstrated low compliance (11.6%) with the United Kingdom's National Patient Safety Agency NG tubes guideline for use of the correct method to check tube position. These separate endeavors led to interdisciplinary collaboration between a medical student, health care professionals, researchers, and industry to develop the Initial Placement Nasogastric Tube Safety Pack. Outcomes Human factors engineering was used to inform pack design to allow guideline recommendations to be accessible and easy to follow. A timeline of product development, mapped against key human factors and medical device design principles used throughout the process, is presented. The safety pack has since been launched in five UK National Health Service (NHS) hospitals, and the pack has been introduced into health care professional staff training for NG tubes. Next Steps A mixed-methods evaluation is currently under way in five NHS organizations.

Original languageEnglish
Pages (from-to)512-516
Number of pages5
JournalAcademic Medicine
Issue number4
Publication statusPublished - 1 Apr 2016

Bibliographical note

Copyright 2016. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

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