Patient deaths lead to NPSA alert over misplaced nasogastric feeding tubes

The Patient Safety Alert updates and strengthens a previous warning issued in 2005, which provided guidance on checking and confirming nasogastric tubes have been inserted correctly into the stomachs of adults, children and babies.

Since the completion date for the 2005 alert a further 21 deaths and 79 cases of harm have occurred due to feeding into the lungs through misplaced devices.

It is unacceptable that patients are still dying from misplaced nasogastric feeding tubes

The main causal factor leading to patient death and harm - in 45 incidents - was misinterpretation of X-rays. The new alert emphasises that pH testing remains the first-line test that a nasogastric feeding tube is inserted correctly. An X-ray must only be used as a second-line check. However, if an X-ray is to be used, the alert supports safe X-ray interpretation.

The latest alert sets out a specific set of steps to go through every time a feeding tube is inserted and asks clinicians to consider three essential questions:

• Is nasogastric feeding the right decision for this patient?
• Is this the right time to place the nasogastric tube and is the appropriate equipment available?
• Is there sufficient knowledge/expertise available at this time to test for safe placement of the nasogastric tube?

The guidance also asks that:

• An ongoing programme of audit is put in place to monitor compliance with the alert across all trusts
• Staff training, competency frameworks and supervision are reviewed to ensure all healthcare professionals involved with nasogastric tube position checks have been assessed as competent
• Purchasing policies are revised and old stock systematically removed to ensure all nasogastric tubes used for the purpose of feeding are radio-opaque throughout their length and have externally visible length markings. This supports safe X-ray interpretation
• Purchasing policies are revised and old stock systematically removed to ensure all pH paper is CE marked and intended by the manufacturer to test human gastric aspirate

Commenting on the warning, Dr Suzette Woodward, director of patient safety at the NPSA, said: “It is unacceptable that patients are still dying from misplaced nasogastric feeding tubes. This new alert emphasises that pH remains the first-line test to ensure the nasogastric tube is in place and provides additional information to support the safe interpretation of X-rays to check the placement of nasogastric tubes. Following these simple steps will make this procedure safer.”