Our Nasogastric Tube Special Interest Group (NGSIG) has written a position paper, “Time to put patient safety first”, which covers the key ways in which nasogastric tube safety has been compromised across Trusts and Health Boards, leading to avoidable Never Events. The paper, published on World Patient Safety Day, urges Trusts and Health Boards to implement a number of recommendations designed to avoid compromising the safety of patients in any future NG procedures.
The paper is clear that the vast majority of nasogastric feeding tubes are passed safely and have their position confirmed using pH checks without issue. However, it also expresses concern at the 276 NG-related Never Events which took place in England alone between 2005 and 2019. These occurred despite four separate NHS Alerts about the deaths and harms caused by misplaced NGTs in that time period.
The paper’s authors advise against giving NGT placement training to all frontline staff and conclude that it should be limited to expert healthcare professionals who receive ongoing support and assessment. It notes that NGT safety must be made the special responsibility of a senior Trust or Health Board member, as mandated in the NHS Alert 2016, with regular reports to the Trust or Health Board, and centrally to the NHS, on their compliance with the 2016 Alert. The paper does also note that ongoing checks of position before each use can be the remit of a greater number of competent staff if necessary.
Wendy-Ling Relph is Chair of the Nasogastric Special Interest Group. She stressed the importance of Trusts and Health Boards taking the lead in following the recommendations outlined: “This paper is not aimed at frontline staff. The root of so many of these Never Events lies in the failure of Trusts and Health Boards to implement recommendations made many times by the NHSI, NHSE and the NHS. This is not only imperative for patient safety, but also for the safety and wellbeing of hospital staff, for whom Never Events can be shattering. We are pleased to launch this on World Patient Safety Day when the theme this year is ‘Safe Health Workers’. Safe NGT placement procedure, training and monitoring is about patient and staff safety.”
Dr Trevor Smith, BAPEN President commented, “It is essential that patient safety is at the top of the agenda of every NHS Trust and Health Board. Nobody in need of artificial nutrition should be at risk of a Never Event, so we endorse the special NGT placement training for a select group of staff in every hospital. Our mission is to ensure everybody receives optimal nutritional care, but it is also important to us to protect frontline healthcare professionals from the risk of avoidable and incredibly distressing mistakes. We hope this paper goes some way to encouraging Trusts and Health Boards to move towards far safer practices.”