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This alert provides new guidance on spinal (intrathecal) devices for chemotherapy that replaces guidance in previous alerts NPSA/2009/PSA004A and NPSA/2011/PSA001. All other guidance in previous alerts remains unchanged.
This alert has been issued in response to two recently reported patient safety incidents, when enteral nutrition was unintentionally given into the respiratory tract through a misplaced nasogastric tube inserted with the aid of a placement device.