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Nasogastric tubes audit

Reference number
Issue date22 February 2010

Nasogastric tube feeding is common practice in all age groups, from neonates to older people. Thousands of feeding tubes are inserted daily without incident, but there is a small risk that the nasogastric feeding tube can be misplaced into the lungs during insertion, or move out of the stomach at a later stage.


Over a two-year period (2003-2005) , the Reporting and Learning Service received reports of 11 deaths and one case of severe harm from misplaced feeding tubes. To reduce harm, the NRLS issued a patient safety alert in 2005 with guidelines for NHS acute trusts, primary care organisations and local health boards. Since the release of the alert, there have been a further 75 cases of feeding through misplaced nasogastric tubes, of which 17 were thought to have directly contributed to patient death.


The NRLS is asking junior doctors to undertake an audit of practices for checking nasogastric tube placement in order to gauge the impact of the alert and guidelines.


Please register to take part. The audit pro forma and accompanying guidance are available to download  below.


This audit is part of a wider initiative to develop a web resource to monitor and evaluate the effectiveness of NRLS products. For further information, please contact jdaudits@npsa.nhs.uk.


Nasogastric tubes audit guidance
Nasogastric tubes audit guidance - 41 KB 1186 | Nasogastric tubes audit guidance | 2010-06
Nasogastric tubes audit pro forma
Nasogastric tubes audit pro forma - 110 KB 1186 | Nasogastric tubes audit pro forma | 2010-06