Nasogastric tube reporting

The safety of nasogastric (NG) tube practice has been highlighted for more than 15 years as one of the original so-called “never events” in which the adverse event is considered wholly preventable. The definition is death or severe harm caused by a misplaced naso- or oro-gastric tube being used and not detected before commencement of feeding, flush or medication administration¹. The highest recent numbers were recorded in the financial years 2020-21 and 2021-22, at 34² and 31³ incidents respectively, spanning the peak periods of the Covid-19 pandemic.

The recommended first-line assessment for NG tube position is pH testing and it remains important for routine cases due to its cost effectiveness and time saving. Confirmation time for NG position using radiographs has been shown to add eight to nine hours⁴ and three times the cost⁵. However, it has been...