Checking placement of nasogastric feeding tubes in adults (interpretation of x ray images): summary of a safety report from the National Patient Safety Agency.

Problems identified by the National Patient Safety Agency Analysis of incidents involving placement of nasogastric feeding tubes since 2005 suggested that misinterpretation of x ray images was the largest single contributory factor, accounting for about half of all serious incidents and deaths. Other f ndings indicated that healthcare professionals were not following the original NPSA guidance. Healthcare staff were: • Feeding patients despite obtaining nasogastric aspirates with a pH of between 6 and 8 • Instilling water down the tube before obtaining an aspirate • Not checking tube placement by any method • Not documenting any confrmation of such checks. Because of the preventable nature of this harm, the misplacement of nasogastric tubes was confrmed by the Department of Health in March 2011 as being a “never” event—that is, one of a restricted list of serious avoidable events that could incur fnancial penalties for providers. Forty one never events relating to misplaced nasogastric tubes were reported between 2009 and 2010, thus confrming problems with interpretation of x ray images and risks in procedures done outside usual working hours. Early results from an NPSA audit in 2010 suggested great variation among 166 junior doctors at fve pilot hospital sites in England and Wales, with low awareness of harm and continued use of unreliable checks such as the whoosh test and testing for acidity with litmus paper. Less than a quarter of the junior doctors were aware of the existing guidance, and less than a third of junior staff surveyed had received formal training on interpretation of x ray images for misplaced tubes.