Misplaced NG Tubes, “Never” Events That Keep Happening

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In January 2017, NHS Improvement (NHSI) published its report on Never Events* that occurred in the NHS between 1 April 2015 and 31 March 2016.  As with previous years misplaced nasogastric (NG) or orogastric (OG) tubes were included in the list of Never Events.

A wide range of incidents are included in the Never Events list and during the period covered, there were a total of 442 confirmed Never Events of which 40 (9.5%) were due to NG or OG tubes being placed into the respiratory tract1. This number was up significantly from 2014-15 when there were only 15 similar Never Events reported. In the current year to date (1 April 2016 – 31 January 2017) there have been 23 prospective NG/OG Never Events reported.

Figure 1.

Given that NG misplacements have been listed as Never Events for a number of years, why have the numbers not reduced and indeed why are they going up?

Perhaps there are clues in the NHSI Level 2 Alert July 20163 which was issued in response to continued incidents and identified significant issues with the misinterpretation of X-Rays and difficulties in using the current methods for pH testing as contributory to the continued occurrence of incidents. The Resource set initial placement checks for nasogastric and orogastric tubes4  issued alongside the alert gave a breakdown in the reasons for NG Never Events from incidents reported to the Strategic Executive Information System (StEIS) database as Serious Incidents or to the National Reporting and Learning System (NRLS) occurring between 12 September 2011 and 11 March 2016.

Of the 95 incidents included the majority (n=68, 72%) were related to misinterpretation of X-Rays (n=45,48%) and pH testing (23, 24%).

Figure 2.

Given that there is a range of research that shows that lack of confidence in current pH testing methods increases the number of X-Rays, the NG Tube position verification method that is most likely to contribute to a Never Event occurring due to misinterpretation. It is perhaps no surprise that little impact has been made on the NG Tube misplacement Never Event figures.

From the information available in the UK, there appears to be an opportunity for a new testing method such as NGPOD to contribute significantly to the reduction of risk in the testing of NG Tube position.

*Never Events are serious, largely preventable patient safety incidents that should not occur if existing national guidance or safety recommendations had been implemented by healthcare providers

1 NHSI Never Events reported as occurring between 1 April 2015 and 31 March 2016 – final update Published 31st January 2017

2 NHSI Provisional publication of Never Events reported as occurring between 1 April 2016 and 31 January 2017 Published 27 February 2017

3 NHSI Patient Safety Alert NHS/PSA/RE/2016/006

4 NHSI Resource set initial placement checks for nasogastric and orogastric tubes July 2016

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