We’ve launched an investigation looking at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.

Nasogastric (NG) tubes are used to deliver fluid, food and medication to patients via a tube that passes through the nose and down into the stomach. 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 feed is passed through them.

Reference event

We started this investigation after we were notified of a patient who inadvertently had a nasogastric tube inserted into his lung.

Investigation summary

This investigation will:

  • Apply a human factors approach to understanding the processes, practices, interactions among people and other elements of system performance involved with the insertion of nasogastric tubes and confirmation of their position.
  • Consider and raise awareness of existing guidance.
  • Consider the procurement and implementation of the equipment required for nasogastric tube insertion and confirmation, and how staff acquire the competencies to do this safely.

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