Nasogastric tube misplacement: continuing risk of death and severe harm

A stage two alert has been issued to support providers of NHS-funded care to prevent the risk of severe harm or death caused by the misplacement of nasogastric tubes (NG tubes).

This short animation explains that it must only ever be staff with the right training who confirm the correct placement of a nasogastric tube.

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

About this alert

This alert highlights patient safety incidents involving the misplacement of nasogastric and orogastric tubes. It is directed at trust boards, or their equivalent in other providers of NHS funded care, to support them in assessing whether previous alerts and guidance has been implemented and embedded within their organisations.

Some of the implementation issues identified in the alert were:

  • problems with systems to ensure staff who were checking tube placement had received competency-based training
  • problems with ensuring bedside documentation formats include all safety critical check
  • problems maintaining safe supplies of equipment, particularly radio-opaque tubes and CE-marked pH test strips

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