Practice Safety Alerts

Insertion of chest drains: summary of a safety report from the National Patient Safety Agency

BMJ 2009; 339 doi: (Published 02 December 2009) Cite this as: BMJ 2009;339:b4923
  1. Tara Lamont, head of response1,
  2. Michael Surkitt-Parr, clinical reviewer1,
  3. John Scarpello[A], deputy medical director,
  4. Marcus Durand, research associate1,
  5. Clare Hooper, pleural research registrar2,
  6. Nick Maskell, consultant physician2
  1. 1National Reporting and Learning Service, National Patient Safety Agency, London W1T 5HD
  2. 2North Bristol Lung Centre, Southmead Hospital, Bristol BS10 5NB
  1. Correspondence to: T Lamont tara.lamont{at}

    Why read this summary?

    Chest drains are often used in the medical management of pleural effusions and pneumothorax. However, the real risks of chest drains are not fully recognised.1 Over three years (January 2005 to March 2008) healthcare staff reported 12 deaths and 15 cases of severe harm from chest drain insertion to the National Patient Safety Agency (NPSA) in England and Wales. True rates of harm to patients are likely to be substantially higher, given that healthcare staff are known to under-report incidents (as is the case with other voluntary reporting systems).2

    Incidents were reported to the agency from a range of settings, including general wards, accident and emergency departments, medical admission units, and intensive care. A typical incident report reads: “Right-sided chest drain inserted into patient. Couldn’t find complete chest drain kit on ward. Tip of drain seen within right lobe of liver. No record of ultrasound performed. Liver injury incurred and patient sent to ITU [intensive therapy unit].”

    This summary is based on a safety report (known as a “rapid response report” or “RRR”) from the NPSA on the risks of chest drain insertion, with key actions for staff.

    Problems identified by the National Patient Safety Agency

    Problems included:

    • Poor selection of site for drain insertion and without use of ultrasonography

    • Inadequate supervision of trainee …

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