The risk of aspiration from orally administered contrast media with spigotted nasogastric tubes
Through its core work to review recorded patient safety events, the National Patient Safety Team identified a risk of harm from the use of spigots (bungs) in nasogastric (NG) tubes.
Nasogastric feeding tubes are fine bore tubes placed through the nasal cavity into the stomach and generally used for administering feed or medication when patients are unable to eat orally. Spigots are bungs inserted into NG tubes, often used after administration of feed or medication to prevent backflow and increase absorption. Spigots may also be indicated before diagnostic imaging in cases of suspected bowel obstruction after enteral administration of contrast agent through the NG tube.
An incident report reviewed by the team outlined how a patient received contrast agent through an NG tube before diagnostic imaging, and a spigot was placed to prevent backflow. The spigot was not removed after the specified time, and the patient sadly died from aspiration of the contrast agent into the lungs.
A review of similar incidents described confusion around how long to keep NG tube spigots insitu and when to use free drainage. There was also variation in practice regarding who administers the contrast agent and when it should be administered. Some incidents reported acute patient deterioration and symptoms of aspiration pneumonia.
The team shared this information with Royal College of Radiologists and Royal College of Surgeons who agreed to collaborate to develop clinical guidance for staff.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.
In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.