Background
  • 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)