The National Patient Safety Agency (NPSA) has issued guidance to NHS organisations in England and Wales aimed at reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants.
The Patient Safety Alert updates and strengthens a previous Alert issued in 2005 which provided guidance on checking and confirming the nasogastric tube had been inserted correctly into the stomach.
Since the completion date for the 2005 Alert a further 21 deaths and 79 cases of harm have occurred due to feeding into the lungs through misplaced nasogastric tubes.
The main causal factor leading to patient death and harm (in 45 incidents) was misinterpretation of x-rays. The new Alert emphasises that pH testing remains the first line test that a nasogastric feeding tube is inserted correctly. An x-ray must only be used as a second line check. However, if an x-ray is to be used, the Alert supports safe x-ray interpretation.
The Patient Safety Alert sets out a specific set of steps to go through every time a nasogastric feeding tube is inserted and asks clinicians to consider three essential questions:
a) Is nasogastric feeding the right decision for this patient?
b) Is this the right time to place the nasogastric tube and is the appropriate equipment available?
c) Is there sufficient knowledge/expertise available at this time to test for safe placement of the nasogastric tube?
The guidance also asks that:
An ongoing programme of audit is put in place to monitor compliance with the Alert.
Staff training, competency frameworks and supervision are reviewed to ensure that all healthcare professionals involved with nasogastric tube position checks have been assessed as competent.
Purchasing policies are revised and old stock systematically removed to ensure all nasogastric tubes used for the purpose of feeding are radio-opaque throughout their length and have externally visible length markings. This supports safe x-ray interpretation.
Purchasing policies are revised and old stock systematically removed to ensure all pH paper is CE marked and intended by the manufacturer to test human gastric aspirate.
Dr Suzette Woodward, Director of Patient Safety, NPSA, said:
“It is unacceptable that patients are still dying from misplaced nasogastric feeding tubes. This new Alert emphasises that pH remains the first line test to ensure the nasogastric tube is in place and provides additional information to support the safe interpretation of x-rays to check the placement of nasogastric tubes. Following these simple steps will make this procedure safer.”
A copy of this Patient Safety Alert and supporting material is available from: www.nrls.npsa.nhs.uk/resources/type/alerts
Notes to editors
1. Media enquiries to the NPSA Press Office:
020 7927 9362 / firstname.lastname@example.org
Out of hours – 0788 411 5956
2. This Patient Safety Alert updates and strengthens Patient Safety Alert 05 (Reducing the harm caused by misplaced nasogastric feeding tubes). It does not replace Patient Safety Alert 09, (Reducing the harm caused by misplaced naso and orogastric feeding tubes in babies under the care of neonatal units), issued August 2005.
3. Misplaced nasogastric or orogastric tubes are on the list of never events for 2011/2012. "Never events" are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place. Further information: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124552
4. Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.
This aspect of our work will continue within the new proposed structure of the NHS Commissioning Board and we will continue to work together in partnership with NHS organisations to make services even safer for patients. We will continue to monitor the implementation of all patient safety alerts and guidance.