Pleural procedures which involve the insertion of intercostal catheters into the pleural cavity incur a high risk of adverse outcomes including death.

The NSW Clinical Excellence Commission has identified 185 reported incidents related to pleural procedures in NSW from January 2010 to October 2011.

Of the 185 pleural procedure incidents there were Severity Assessment Code (SAC) 1 (n=6) and SAC 2 (n=5) adverse events.

Clinical management was attributed as the principal incident type in 69% of all incidents reported.

Incidents related to pleural drains occurred in both metropolitan and regional facilities and within operating theatres, critical care units, emergency departments, specialised surgical and medical wards, general wards and medical imaging departments.

Ten pleural drain risk reduction strategies

1. Do not insert a pleural drain out of hours except in an emergency.
2. Do not proceed with any pleural drain procedure if you do not feel fully confident.
3. Do not proceed with pleural drain insertion without further imaging if air (in the case of pneumothorax) is not confirmed at the time of local anaesthetic infiltration, including at the time of needle decompression if a suspected tension pneumothorax.
4. Do not insert a pleural drain:
   • for pleural effusion outside the triangle of safety without ultrasound guidance
   • for pneumothorax in a position other than 5th intercostal space in the mid axillary line or 2nd intercostal space in the mid clavicular line without ultrasound guidance.
5. Do not proceed with insertion of a pleural drain without ultrasound guidance if fluid (in the case of an effusion) is not aspirated at the time of local anaesthetic infiltration.
6. Do not insert a pleural drain through breast tissue.
7. Do not use force when the guide-wire or intercostal catheter is not moving easily during insertion.
8. In the event of accidental dislodgement or removal of pleural drain - do not re-insert the same tube or a new tube into the previous site.
9. Do not clamp a pleural drain when transporting the patient.
10. Do not clamp a bubbling pleural drain.