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