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Substances inadvertently administered-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

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

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]

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

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.