Abstract
Nasogastric tube (NGT) insertion is commonly performed but mismanagement of NGTs can have disastrous consequences for patients. Administration of feed, fluid or medication through a tube which has been incorrectly placed in the respiratory tract has been and NPSA ‘Never Event’ since 2009. Despite the focus on safe usage, between 2011 and 2016 there were 95 reported incidences of fluid or medication being introduced into the respiratory tract via an incorrectly placed NGT1. There were two incidences of this in Lancashire Teaching Hospitals NHS Foundation Trust (LTHTr) in 2016. Improved education in the identification of incorrectly placed NGTs is required to help address this patient safety issue.
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