Improving the safety of nasogastric tube confirmation in a District General Hospital

Abstract

Nasogastric tube (NGT) misplacement continues to present a risk of death and severe harm to patients. Despite multiple NHS Improvement Patient Safety Alerts and iterations on guidelines around NGT safety, there continue to be reported incidents of misplaced NGTs. Between September 2011 and March 2016, 95 incidents of misplaced NGTs were reported to the NRLS and/or the StEIS (1). Incident reports cite misinterpretation of CXRs by non-trained medical staff as the most common error. We sought to identify and compare local practice of doctors confirming NGT placement against national standards.