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Chest drains: risks associated with the insertion of chest drains

Rapid Response Report: Risks of chest drain insertion - thumbnail image
Reference number
1065
Central Alert System (CAS) reference
NPSA/2008/RRR003
Issue date01 May 2008
Action date (if applicable) (date field)17 November 2008
DH Gateway reference
9871
TypeAlert
This Rapid Response Report alerts all healthcare staff to the risks associated with the insertion of chest drains.


Chest drains are used to remove air, blood, pus or fluid from the pleural cavity. They may be used in patients with collapsed lungs, malignancies, chest trauma or after surgery. It is a common procedure, but when not inserted properly they may puncture major organs such as heart, lungs, liver and spleen.


The National Reporting and Learning Service received reports of 12 deaths relating to chest drain insertion and 15 cases of serious harm between January 2005 and March 2008. A substantial number of less severe incidents were reported, highlighting poor management of inserted chest drains.


Common themes from a review of reported incidents include:

  • inadequate staff supervision and experience;
  • failure to follow manufacturers instructions;
  • the site of insertion and poor positioning;
  • anatomical anomalies and the patients clinical condition; and
  • lack of knowledge of existing clinical guidelines.


Clinical governance leads in local organisations should audit current practice and develop local policies to ensure that:


  • chest drains are only inserted by adequately supervised competent staff;
  • ultrasound guidance is strongly advised when inserting a drain for fluid;
  • clinical guidelines are followed and staff made aware of the risks;
  • patients give written consent before the procedure, wherever possible; and
  • local incident data relating to chest drains is reviewed and staff encouraged to report further incidents.

Chest drain insertion - Rapid Response Report
Chest drain insertion - Rapid Response Report - 92 KB 1065 - Chest drain insertion - Rapid Response Report - 2008-05 - V1
Chest drain insertion - Rapid Response Report supporting information
Chest drain insertion - Rapid Response Report supporting information - 102 KB 1065A - Chest drain insertion - Rapid Response Report supporting information - 2008-05 - V1