PA Reporting-Tuesday Tube Facts


  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. Pennsylvania Patient Safety Advisory. 2017. 14:1-60.

Never Event in England-Tuesday Tube Facts

Did you know…?

In England, misplacement of a naso- or oro-gastric tube in the pleura or respiratory tract that is not detected before starting a feed, flush or medication administration is considered a ‘Never Event’.[1]

Never events are defined as ‘serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic barriers are available at a national level and should have been implicated by all healthcare providers’.[2]


  1. NHS Improvement. Never Events list 2018; 2018. https://improvement.nhs.uk/documents/2899/Never_Events_list_2018_FINAL_v7.pdf. Accessed 15 September 2020.
  2. NHS Improvement. Never Events policy and framework. Revised 2018. https://improvement.nhs.uk/documents/2265/Revised_Never_Events_policy_and_framework_FINAL.pdf. Accessed 15 September 2020.

EAD Misplacement into Lung Can Lead to Death – Tuesday Tube Facts

EAD Misplacement into Lung Can Lead to Death – Tuesday Tube Facts

Of the 1.2 million small bore feeding tubes placed, about 0.1-0.3% of patients die as a result of blind misplacement.*

About 1.2–2 percent of small bore feeding tubes that are placed blindly at the bedside enter the airway undetected. *

* Krenitsky, J. Blind Bedside Placement of Feeding Tubes: Treatment or Threat? Practical Gastroenterology. 2011; March, 32-42.