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The danger of tube misconnections – Tuesday Tube Fact

Feb 22, 2022 | Tuesday Tube Facts

Did you know…?

It is common to see patients in the hospital with a feeding tube, an arterial catheter, and a central venous catheter, which all have the same connector. A misconnection is physiologically incompatible with life, and if enteral feeding is placed inside the IV line, it would be like concrete pouring into a patient’s heart.[1]

References:

  1. Simmons, Debra. “Keeping Everyone Safe: Tubing Misconnections.” The Oley Foundation, accessed 21 Feb. 2022, https://oley.org/page/DebSimmonsTubeMis

Substances inadvertently administered-Tuesday Tube Facts

Oct 12, 2021 | Tuesday Tube Facts

Did you know…?

In one study over a 5-year period, 95 incidents were reported to the National Reporting and Learning System in which substances were inadvertently administered through NG tubes into the respiratory tract, resulting in 32 patient deaths. [1]

References:

  1. Powers, J, Brown, B, Lyman, B, et al. Development of a competency model for placement and verification of nasogastric and nasoenteric feeding tubes for adult hospitalized patients. Nutr. Clin. Pract. 2021; 36: 517-533. https://doi.org/10.1002/ncp.10671

PA Reporting-Tuesday Tube Facts

Apr 6, 2021 | Tuesday Tube Facts

Did you know…?

Pennsylvania is one of few states that requires reporting of misplaced nasogastric feeding tubes.[1]

From 2011-2016 the Patient Safety Authority (PSA) documented 166 nasogastric tube misplacements with 56% (n=93) documented to have caused serious harm and 137 placed into the lung.[2]

Read the Full Story

References:

  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

Apr 2, 2021 | 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]

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References:

  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

May 14, 2019 | 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.