A patient safety alert has been issued today (5 December 2013) by NHS England on the use of placement devices for inserting nasogastric tubes. This alert has been issued via the Central Alerting System (CAS) to ensure all hospitals and community services that use nasogastric tubes continue to follow previous guidance issued by the National Patient Safety Agency (NPSA), even when placement devices are used.
The previous NPSA patient safety alert Reducing the harm caused by misplaced nasogastric tubes in adults, children and infants (2011) stated that a pH of 1 to 5.5 or an x-ray are the only acceptable methods for confirming initial placement of a nasogastric tube.
This alert has been issued in response to two recently reported patient safety incidents, when enteral nutrition was unintentionally given into the respiratory tract through a misplaced nasogastric tube inserted with the aid of a placement device.
Dr Mike Durkin, National Director of Patient Safety, NHS England, said: “Patient safety alerts are a crucial part of our work to rapidly alert the healthcare system to risks and provide guidance on preventing potential incidents that may lead to harm or death. These incidents are uncovered using our reporting system to spot emerging patterns at a national level, so that appropriate guidance can be developed and issued to protect patients from harm.”