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Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants

Reference number
1253
Central Alert System (CAS) reference
NPSA/2011/PSA002
Issue date10 March 2011
Action date (if applicable) (date field)12 September 2011
DH Gateway reference
15694
TypeAlert

This Alert updates and strengthens Patient Safety Alert 05 (Reducing the harm caused by misplaced nasogastric feeding tubes) and is based on national learning since then.


All organisations in the NHS and independent sector where nasogastric feeding tubes are placed and used for feeding patients should ensure, through reviewing policies, procedures and staff training that by 12 September 2011:


1. A named clinical lead is assigned to have responsibility for implementing all actions in this Alert.


2. All policies, protocols, and bedside documentation are reviewed to ensure compliance with steps (a) to (j) outlined on page 2 every time a nasogastric
tube is inserted and used to administer medication, fluids or feed.


3. An ongoing programme of audit is put in place to monitor compliance.

 

4. 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. Competency training should include theoretical and practical learning. An example eModule training tool for x-ray interpretation of nasogastric tube position is available at www.esrsupport.co.uk/nlms/login.html (in addition refer to guide to interpretation on page 3 of this Alert).


5. 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.


6. 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.*

* Medicines and Healthcare products Regulatory Agency. Medical Device Alert: Medical devices in general and non-medical products (MDA/2010/001).

 

Please note: From 1 June 2012 all enquiries related to alerts (Rapid Response Reports, Patient Safety Alerts, Safer Practice Notices etc) should be directed to the Central Alerting System Helpdesk: safetyalerts@dh.gsi.gov.uk.

 

 

Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants
Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants - 2.06 MB 1253 | Nasogastric feeding tubes Alert | 08-03-2011 | v1
Nasogastric feeding tubes Alert - supporting information
Nasogastric feeding tubes Alert - supporting information - 293 KB 1253 | Nasogastric feeding tubes Alert - supporting information | 08-03-2011 | v1.
Nasogastric feeding tubes - decision tree adults
Nasogastric feeding tubes - decision tree adults - 128 KB 1253 | Nasogastric feeding tubes decision tree adults | 08-03-2011 | v1
Nasogastric feeding tubes - decision tree children and infants
Nasogastric feeding tubes - decision tree children and infants - 128 KB 1253 | Nasogastric feeding tubes - decision tree children and infants | 08-03-2011 | v1