Misplaced nasogastric tubes leading to death or severe harm are ‘never events.’
The NPSA is aware of two patient deaths since 10 March 2011 where staff had flushed nasogastric tubes with water before initial placement had been confirmed. Staff then aspirated back the water they had flushed into the tube, including the lubricant within the tube that this water had activated. Because this mix of water and lubricant gave a pH reading below 5.5, they assumed that the nasogastric tube was correctly placed and went on to give medications and/or feed, although the tube was actually in the patient’s lung. We are also aware of a similar incident which did not lead to harm to a patient.
The three organisations where the incidents occurred were aware of the NPSA Alert, Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants, but there appeared to be a widespread belief amongst their frontline staff that the ‘never flush’ rule did not apply where nasogastric tubes had a water-activated lubricant.
This belief is incorrect, and the manufacturer’s written guidance, enclosed with each new nasogastric tube, clearly states that gastric placement must be confirmed BEFORE the tube is flushed. The lubricant is not needed for placement, only to aid removal of the guidewire/ stylet from the tube after gastric placement has been confirmed.
All organisations in the NHS and independent sector where nasogastric feeding tubes are placed and used for feeding patients should ensure:
1. Assign a named clinical lead to coordinate implementation of the actions in this Rapid Response Report (RRR) with any actions outstanding from the earlier Alert
2. Remind all staff responsible for checking initial placement of nasogastric tubes (including staff who support parents/carers who check initial placement of nasogastric tubes):
a. NOTHING should be introduced down the tube before gastric placement has been confirmed;
b. DO NOT FLUSH the tube before gastric placement has been confirmed;
c. Internal guidewires/ stylets should NOT be lubricated before gastric placement has been confirmed.
3. This reminder should be given through:
a. Distributing this RRR to all relevant staff;
b. Providing warning notices and/ or overwraps with warning labels on all current and future stock of nasogastric tubes, until these are provided as standard by manufacturers;
c. Reviewing and, if necessary, amending all local policy, protocol and training materials.