There are several factors within this scenario which contributed to the

patient being fed via a misplaced tube

They fall into five main categories:

Human factors (e.g. difficulty interpreting X ray)

Equipment factors (e.g. use of less radiopaque tubes rather than

ones that are completely radiopaque)

System factors (e.g. limited access to out-of-hours specialist

radiology help)

Environmental factors (e.g. workload issues leading to delays)

Communication factors (e.g. documentation in the notes is often

poor - when re-siting tubes it is important to know if there have

been previous difficulties placing the tube)