Why do Misplaced Nasogastric (NG) Tube Never Events continue to be reported?

Never Event Categories

The variation in the categories of Never Events reported between April and June 2020 compared to historical patterns may be reflective of the changes in activity within the NHS, as before the suspension of many surgical procedures, a significant proportion of the total Never Events were associated with these activities.

Of the 60 Never Events that have been reported so far, seven are associated with misplaced NG, or OG tubes1which represents 12% of the total (Fig 1). While proportionally to the total number of Never Events, this is a significant increase compared to historical figures, as the absolute number of NG related Never Events continued its upwards trend (Fig 2).

A new development for the latest NHSI Never Event figures is that for the first time they include a breakdown of the likely cause of NG related Never Events. The reasons listed are consistent with those described as causes for NG related Never Events in the Resource set initial placement checks for nasogastric and orogastric tubes2 which was issued alongside the NHSI Level 2 Alert July 20163.

Of the 7 events reported this year so far:

• 3 related to placement checks that were not described
• 3 related to X-ray misinterpretation; no indication ‘four criteria’ used
• 1 related to X-ray showing respiratory tract placement, although it is unclear why feed commenced despite this

The NHSI Resource set for initial placement checks for nasogastric and orogastric tubes2 analysed the reasons for NG tube Never Events. The analysis included 95 incidents reported to the Strategic Executive Information System (StEIS) database or to the National Reporting and Learning System (NRLS) that occurred between September 2011 and March 20162.

Of these 95 incidents, the majority pertained to the misinterpretation of X-Rays (48%) and pH testing (24%). The latest provisional data is congruent with the previous reports, as it shows that three out of the seven NG related Never Events were due to misinterpretation of X-ray.

NHSI released an educational video4 shortly after the NHSI Level 2 Alert in July 2016, which reiterated traditional methods for checking NG tube placement, such as only checking tip placement, is not safe. Staff must use the full ‘four criteria’ for interpreting X-ray to confirm an NG tube has been correctly placed.

Despite six patient safety alerts issued by NHSI (formerly NPSA) and a continued effort towards patient safety from healthcare professionals, the number of NG related Never Events continues to rise.

Research shows that in addition to the difficulty in obtaining aspirate and interpreting the results of pH strips, clinicians also lack confidence in this method of pH testing leading to X-Rays, the leading cause of NG related Never Events being used more often to determine NG tube placement.

NGPOD® is a new method of pH testing to determine correct NG Tube position, which removes the need to obtain aspirate and reduces the potential for human error by providing a clear, positive or negative result which does not require interpretation by the operator.  For more information on NGPOD®, please click this link here contact us.

*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

References

1. NHSI Provisional publication of Never Events reported as occurring between 1 April and 30 June 2020 https://www.england.nhs.uk/wp-content/uploads/2020/08/Provisional_publication_-_NE_1_April_-_30_June_2020.pdf
2. NHSI Resource set for initial placement checks nasogastric and orogastric tubes  https://improvement.nhs.uk/resources/resource-set-initial-placement-checks-nasogastric-and-orogastric-tubes/
3. NHSI Level 2 Alert July 2016 https://improvement.nhs.uk/documents/194/Patient_Safety_Alert_Stage_2_-_NG_tube_resource_set.pdf
4. Nasogastric tube misplacement: continuing risk of death and severe harm https://www.england.nhs.uk/2016/07/nasogastric-tube-misplacement-continuing-risk-of-death-severe-harm/