The UK National Health Service’s National Patient Safety Agency published a report entitled ‘Risks of chest drain insertion’, reporting 12 deaths and 15 cases of serious harm related to chest drain insertion over a three year period. They issue the following recommendations under the title ‘For IMMEDIATE ACTION by the NHS and independent sector – Deadline for ACTION COMPLETE is 17 November 2008’:
Clinical governance leads in local organisations should audit current practice and develop local policies to ensure:

• Chest drains are only inserted by staff with relevant competencies and adequate supervision
• Ultrasound guidance is strongly advised when inserting a drain for fluid
• Clinical guidelines are followed and staff made aware of the risks
• Identify a lead for training of all staff involved in chest drain insertion
• Written evidence of consent is obtained from patients before the procedure, wherever possible
• Local incident data relating to chest drains is reviewed and staff encouraged to report further incidents

Chest drains: risks associated with the insertion of chest drains
National Patient Safety Agency