The NPSA has published a list of 'never events' which are specific serious
untoward incidents that can cause serious harm but should be avoidable if national
guidance is followed(1)
One Never Event relates to: Death or severe harm due to a misplaced naso-or
oro-gastric tube being used where the misplacement of the tube is not detected
prior to commencement of feeding, flush or medication administration is such a
Never Event. Naso or orogastric tubes placed in the respiratory tract rather than
the gastrointestinal tract and not detected prior to commencing feeding or other
use' (1)
The Quarterly Data Summary estimates 271,000 nasogastric tubes are purchased
by the NHS annually (2)
Since the 2005 NPSA alert, the NRLS has received reports of a further 21 deaths
and 79 cases of harm due to feeding into the lungs through misplaced nasogastric
tubes. The main causal factor leading to harm was misinterpretation of X-rays.
This was found in 45 incidents, 12 of which resulted in the death of the patient.
This e-Learning module as been recommended in the March 2011 Alert (3)