Hit the target

Wrongly inserting a nasogastric tube can have deadly consequences. A recent Casebook article outlines how to avoid these risks

Photo by St. MurseIn 2010 75-year-old Maurice Murphy died in hospital as a result of a misplaced nasogastric tube. He was being treated for liver failure and required a nasogastric (NG) tube to be inserted. Unfortunately this ended up in his right lung instead of his stomach and feeding commenced, resulting in fatal pneumonia.

At the inquest it emerged that a junior doctor was challenged by a nurse to confirm that the tube was in the right place. The doctor in question overruled her, saying: “You don’t have a brain to remember that I told you to start the feed as the tube is in the right position.” It also emerged that there was an x-ray flagging the error. So why hadn’t anyone seen it? It would appear that a combination of factors led to the death of Mr Murphy – the misplaced confidence of the junior doctor, the fact the standardised procedure for inserting a tube was not followed, and that the x-ray was not reviewed.

This case report highlights just how careful you have to be. There are big risks associated with NG tubes, and if a misplaced tube is not spotted before feeding, patients can suffer complications like pneumonia, which can be fatal.

Avoiding the risks

Individual clinicians should consider the following before going through with the procedure:

• Is nasogastric feeding right for this patient?
• Does this need to be done now?
• Am I competent to do this?
• How can I check the right amount of tube has been inserted?
• Do I know how to test for correct placement?
• What is a safe pH level?
• When should I get an x-ray?
• What should I look for on the x-ray?
• What about repeat checks?

Did you know?

• The ‘whoosh’ test is unreliable in detecting the placement of NG tubes. The NPSA recommends pH testing using pH indicator paper as a first-line check – pH levels between 1 and 5.5 are safe.
• The NPSA was notified of 21 deaths and 79 cases of harm due to misplaced NG tubes between 2005 and 2011. The single greatest cause of harm was due to misinterpretation of x-rays. A chest x-ray is required if the first-line check fails to prove the NG tube is safe for use.
• Flushing NG tubes with water before placement can cause a pH reading of below 5.5 because of the mix of water and lubricant – this can cause practitioners to assume that NG tubes are correctly placed, when they are not.

The National Patient Safety Agency (NPSA) has issued many warnings about the dangers of nasogastric tubes over recent years. The most recent alert was in March 2012, when they issued Rapid Response Report, Harm from flushing of nasogastric tubes before confirmation of placement [1]. The NPSA is aware of two patient deaths since March 2011 where staff had flushed nasogastric tubes with water before initial placement had been confirmed. This is extremely dangerous and all medical staff should be aware that gastric placement must be confirmed before the tube is flushed.

The NPSA states that “misplaced nasogastric tubes leading to death or severe harm are ‘never events’.” Never events are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place.

The full Casebook article, Nasogastric tube errors, can be read here – http://www.medicalprotection.org/uk/casebook-september-2012/nasogastric-tube-errors.