+ Site Statistics
+ Search Articles
+ PDF Full Text Service
How our service works
Request PDF Full Text
+ Follow Us
Follow on Facebook
Follow on Twitter
Follow on LinkedIn
+ Subscribe to Site Feeds
Most Shared
PDF Full Text
+ Translate
+ Recently Requested

Patient safety matters: reducing the risks of nasogastric tubes



Patient safety matters: reducing the risks of nasogastric tubes



Clinical Medicine 10(3): 228-230



Nasogastric tube insertion is a common clinical procedure carried out by doctors and nurses in NHS hospitals daily. For the last 30 years, there have been reports in the medical literature of deaths and other harm resulting from misplaced nasogastric tubes, most commonly associated with feed entering the pulmonary system. In 2005 the National Patient Safety Agency in England assembled reports of 11 deaths and one incident of serious harm from wrong insertion of nasogastric tubes over a two-year period. The agency issued a safety alert setting out evidence-based practice for checking tube placement. In the two and a half years following this alert the problem persisted with a further five deaths and six instances of serious harm due to nasogastric tube misplacement. This is a potentially preventable error but safety alerts advocating best practice do not appear to reliably reduce risk. Alternative solutions, such as standardising procedures, may be more effective.

Please choose payment method:






(PDF emailed within 0-6 h: $19.90)

Accession: 054889811

Download citation: RISBibTeXText

PMID: 20726449

DOI: 10.7861/clinmedicine.10-3-228


Related references

Checking placement of nasogastric feeding tubes in adults (interpretation of x ray images): summary of a safety report from the National Patient Safety Agency. Bmj 342: D2586, 2011

SAFETY ALERTS: Reducing risks of tourniquets left on after finger and toe surgery: summary of a safety report from the National Patient Safety Agency. Bmj 340(7753): 973-974, 2010

Reducing risks of tourniquets left on after finger and toe surgery: summary of a safety report from the National Patient Safety Agency. Bmj 340: C1981, 2010

Nasogastric tubes. 2: Risks and guidance on avoiding and dealing with complications. Nursing Times 105(17): 14-16, 2009

NHS safety agency issues guidance on nasogastric tubes. Bmj 330(7489): 438, 2005

Fine-bore nasogastric tube feeding: reducing the risks. British Journal of Nursing 27(12): 674-675, 2018

The insertion of nasogastric tubes in the anaesthetized patient. Anaesthesia 28(3): 341-342, 1973

An incremental step in patient safety: reducing the risks of retained foreign bodies by the use of an integrated laparotomy pad/retractor. Surgical Innovation 15(3): 203-207, 2008

Safety and effect of metoclopramide to prevent pneumonia in patients with stroke fed via nasogastric tubes trial. Stroke 46(2): 454-460, 2015

Gastroesophageal reflux with nasogastric tubes. Effect of nasogastric tube size. American Journal of Respiratory and Critical Care Medicine 149(6): 1659-1662, 1994

The use of nasogastric feeding tubes in nursing homes: patient, family and health care provider perspectives. Gerontologist 30(4): 469-479, 1990

PTH-035Pulmonary Misplacement Of Nasogastric Tubes: A 2 Year Audit Of Service Delivery, Feedback Intervention And Patient Outcome. Gut 63(Suppl 1): A223.2-A224, 2014

Nasointestinal tubes versus nasogastric tubes in the management of small-bowel obstruction: A meta-analysis. Medicine 97(36): E12175, 2018

Long tubes vs nasogastric tubes in the treatment of intestinal obstruction. Archives of Surgery 122(1): 118, 1987

Dual-Purpose Gastric Decompression and Enteral Feeding Tubes Rationale and Design of Novel Nasogastric and Nasogastrojejunal Tubes. Jpen. Journal of Parenteral and Enteral Nutrition 39(5): 531-543, 2016