Nasogastric Tube Misplacement related Never Events are rising: By how much, and why?

29 NG Tube Never Events in 24 Trusts

With three months of the reporting year remaining, this figure is already higher than three of the four preceding years. If the trend continues, it will result in a final total of 37 NGT Never Events in 2020-2021.

Use of a misplaced NG tube is the third most frequently reported Never Event so far this year after Wrong-site surgery (131) and Retained foreign object post-procedure (70).

The 29 reports of NGT related Never Events reported to date occurred in 24 different NHS Trusts.

For the first time this year, NHS Improvement has included additional information on NGT Never Events’ cause.  2020-21 shows that, as in previous years, the misinterpretation of x-rays is the most frequent cause, followed by placement checks that were not described or were not clearly described.

There are multiple potential causes for the increase in NG tube Never Events in the last year.  There has been increased use of NG tubes as part of the treatment for Covid-19 patients and the need to administer nutrition, hydration and medication to these patients while positioned supine or prone.  

The recent NHS Improvement, Healthcare Services Investigation Branch report (Dec 2020) identifies a myriad of risks associated with current methods of placement confirmation. Among these are:

• “…both pH testing and use of X-ray are prone to error…”
• “…using pH testing strips is potentially unreliable and its complexity underestimated…”
• “The investigation also identified concerns about the reliability and usability of pH strips.”
• “The environment within which pH testing strips are being interpreted can increase the risk of error.”
• “…causes included misinterpretation of pH testing of gastric aspirate, use of outdated checking methods use of outdated checking methods…”

Many of these flaws may have been exacerbated by the pandemic’s pressures, not least the need to obtain aspirate and interpret a pH strip or x-ray result while wearing PPE.

It is unclear what the underlying cause(s) of the increase in NG tube Never Events this year is, and the answer may be complex.

One significant contributing factor seems likely to be the limitations of the currently widely used NGT placement confirmation methods, which have remained unchanged for many years despite their well-recognised flaws.