Patient Safety Alert: Reducing the harm caused by misplaced nasogastric
feeding tubes
In 2005 the NPSA released a Patient Safety Alert with guidance on placementchecks after nasogastric tube insertion. This followed reports of patient death as a
result of feeding through misplaced nasogastric tubes.1
Since that Alert, the National Reporting and Learning System (NRLS) received
reports of a further 21 deaths and 79 cases of severe harm due to misplaced
nasogastric tubes. In 45 cases the harm was due to misinterpretation of X-rays by
clinical staff, of which 12 resulted in death.
Feeding into the lung through a misplaced nasogastric tube is now a Never
Event2 in England.
Actions for the NHS by (six months after issue)
All organisations in the NHS and independent sector where nasogastric tube feeding
is initiated should ensure that:
1. The decision to commence nasogastric tube feeding is only made following a
multidisciplinary team needs assessment. This team should include, as a
minimum, the senior doctor responsible for the patient’s care, a senior ward
nurse and a dietitian/speech and language therapist (SALT). The details of
this assessment must be recorded in the patient’s medical notes prior to
commencement of feed.
2. Elective placement of nasogastric feeding tubes does not occur outside of
normal working hours.
3. pH testing is the first line testing method following nasogastric feeding tube
insertion2. All areas where nasogastric feeding tube placement is likely to
occur should have access to CE marked pH indicator paper.
4. X-rays are only used as a second line test where pH indicator paper has
failed to confirm the location of the nasogastric tube.
5. Whoosh tests,3,4,5,6 interpretation on the appearance of aspirate,5,6,7 and the
use of acid/alkaline test using litmus paper8,9 are not used as confirmatory
tests as these are not reliable.
6. All test results are recorded in the patient’s medical notes prior to
commencement of feed.
7. All staff caring for patients with nasogastric feed are made aware of these
guidelines and have access to the decision trees and X-ray interpretation aid
(included with this Alert).
8. All doctors involved with nasogastric tube position checks have formal
competency training in X-ray interpretation. This should entail completion of
the NPSA nasogastric tube eModule [in development] or a similar locally
derived and approved learning module.
References
1. National Patient Safety Agency: Reducing harm caused by the misplacement
of nasogastric feeding tubes; Patient Safety Alert 05; Feb. 05. Available
online at http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59794
2. National Patient Safety Agency: Never Events Framework 2009-2010;
guidance; Feb. 09. Available online at
http://www.nrls.npsa.nhs.uk/resources/collections/neverevents/?entryid45=59859
3. Metheny N, Dettenmeier P, Hampton K, et al. Detection of inadvertent
respiratory placement of small-bore feeding tubes: a report of 10 cases. Heart
Lung 1990;19(6):631-8.
4. Neumann MJ, Meyer CT, Dutton JL, et al. Hold that X-ray: aspirate pH and
auscultation prove enteral tube placement. J Clin Gastroenterol
1995;20(4):293-5.
5. Kearns PJ, Donna C. A controlled comparison of traditional feeding tube
verification methods to a bedside, electromagnetic technique. JPEN J
Parenter Enteral Nutr 2001;25(4):210-5.
6. Seguin P, Le Bouquin V, Aguillon D, et al. [Testing nasogastric tube
placement: evaluation of three different methods in intensive care unit]. Ann
Fr Anesth Reanim 2005;24(6):594-9.
7. Metheny N, Reed L, Berglund B, et al. Visual characteristics of aspirates from
feeding tubes as a method for predicting tube location. Nurs Res
1994;43(5):282-7
8. MHRA Medical Device Alert MDA/2004/026 June 2004. Available online at
http://www.mhra.gov.uk
9. Rollins H (1997) A nose for trouble. Nursing Times, December 3, Volume 93,
No 49, 66-67.