There may be a greater risk of pneumonia following a malpositioned feeding tube.*
In one study of patients who experienced a malpositioned feeding tube, 40% developed pneumonia at the former site of the malpositioned tube.*
| * Giantsou, E.; Gunning, K. J. Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care. Health, Cambridge University Hospitals NHS Trust. 2010. 2(10): 1135-1141. |
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A replacement feeding tube perforated bronchial tissue, leading to a patient’s death.*
The feeding tube was replaced due to a clog.*
The patient passed away just 65 minutes after the attempt to replace the feeding tube.*
* Smith, A.L., Santa Ana, C.A., Fordtran, J.S., Guileyardo, J.M. Deaths associated with insertion of nasogastric tubes for enteral nutrition in the medical intensive care unit: Clinical and autopsy findings. Baylor University Medical Center Proceedings, 2018;31(3):310-316.
Nearly 68% of malpositioned nasogastric feeding tubes occurred in adults between 60 and 89 years old.*
These events took place in Pennsylvania between 2011 and 2016. About half of the misplacements were discovered with a chest x-ray.*
* Wallace SC. Data Snapshot: Complications Linked to Iatrogenic Enteral Feeding Tube Misplacements. Pennsylvania Patient Safety Advisory, 2017; 14:1-60.
In Pennsylvania, 56% of nasogastric feeding tube misplacements were reported as Serious Events.1
1.2% of those misplacements resulted in death.1
In 2016, a $5 million verdict was awarded following a patient’s death due to a misplaced feeding tube at a Philadelphia-area hospital.2
1. Wallace, SC. Data Snapshot: Complications Linked to Iatrogenic Enteral Feeding Tube Misplacements. Pennsylvania Patient Safety Advisory, 2017; 14:1-60.
2. McCrystal, Laura. (2016, 16 May). Montco jury awards $5 million in hospital death [online]. The Inquirer. Accessed July 8, 2019
Pennsylvania is one of few states that requires reporting of misplaced* nasogastric feeding tubes.1
Between 2011 and 2016, 166 enteral tube misplacements were documented in Pennsylvania.2
| * Complications after enteral access device (EAD) placement can include misplacement, which is when the tip of the EAD is placed in an anatomical position not intended for the proper administration of enteral nutrition. |
| 1. Irving, S., Rempel, G., Lyman, B., Sevilla, W., Northington, L., Guenter, P. Pediatric Nasogastric Tube Placement and Verification: Best Practice Recommendations From the NOVEL Project. Nutrition in Clinical Practice, 2018; 33(6):921-927. 2. Wallace, S.C. Data Snapshot: Complications Linked to Iatrogenic Enteral Feeding Tube Misplacements. PA Patient Safety Authority, 2017; 14:1-60. |
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