A Pennsylvania healthcare facility requested guidance from the Pennsylvania Patient Safety Authority about issues arising from misplacements of small-bore nasogastric feeding tubes after switching to a different brand of an enteral feeding delivery system. The facility wanted to know if other hospitals were experiencing similar types of adverse events. Analysis of events reported to the Authority from January 2011 through October 2013 revealed 44 reports that described misplacements of small-bore nasogastric feeding tubes. It is estimated that more than 1.2 million small-bore feeding tubes are used annually in the United States. Analysis of events reported to the Authority (1) indicates an increase in reports of small-bore nasogastric feeding tube misplacements from January 2013 to October 2013 compared with the previous two years, (2) offers possible explanations for why this increase in malpositions may have occurred, and (3) suggests strategies facilities can take to reduce the risk of experiencing this adverse event, including staff training and combining placement practices.
Copyright:
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)