• Given the potential catastrophic consequences of tube misplacement, the NPSA
  • designated feeding after NG tube misplacement as one of 25 'never events' 1
    •  
  • Misplaced naso- or oro-gastric tubes. 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.
  • Where appropriate checks are conducted and documented and demonstrate that
  • the tube is in the correct place, but the tube is subsequently found to have become
  • misplaced, for example after becoming dislodged, provided there has been regular
  • checking of tube placement, this is not a never event. Setting: All healthcare
  • premises.
    •  
  • This means there needs to be a system in place to help avoid the never event taking
  • place
    •  
  • This training package is part of that safety system 
    •  
    1.https://www.gov.uk/government/news/never-events-list-update-for-2012-13
    NPSA 'never events'