HSIB report: Placement of nasogastric tubes

Data from NHS supply chain shows that each year at least 967,977 NG tubes are purchased in the NHS in hospitals and community settings (care home and home).

NG tubes have been the subject of numerous patient safety alerts in the last 15 years. There is a risk of serious harm and risk to life if NG tubes are incorrectly placed into the lungs rather than the stomach and fluid, medicine or feed is passed through them. Such incidents are classified as a Never Event (NHS Improvement, 2018a).

The safety risk of misplaced NG tubes was referred to the Healthcare Safety Investigation Branch (HSIB) as a potential national investigation due to the persistence of harm despite several patient safety alerts. The referrer reported concerns that both pH testing and use of X-ray are prone to error; these concerns are supported by previous patient safety alerts and literature. The referrer believed that opportunities for error existed for all levels of staff, and that seniority did not necessarily reduce the risk.