Patient safety alert on placement devices for nasogastric tube insertion

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.”

You can read the full Placement devices for nasogastric tube insertion DO NOT replace initial position checks patient safety alert here.

One comment

  1. Brenda Ussery says:

    This has been a concern for a long time. The medical community are gonna have to make a true and universal determination to protect both the client/patient and the professional medical staff.
    I realize cost as well as radiation tilts to not completely setting a determination but a decision must be affirmed. I pray GOD it won’t take a huge media report on some mega super star or governmental somebody or renown noble soul to have that “one in a million” proverbial oopsy, for us as nurses and doctors, scientists, and research genius to do what should have been done. My Mom always said never come to the table with a complain if you don’t have an ideal to try.
    My idea: xray initially… 2 professional medical staff members q 24 hours, and the nurse assigned q shift, as well as q monthly replace and xray confirmation.