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Focus on patient safety - "Changing a nasogastric tube in adults. Incorrect placement and it’s straight to intensive care"

Flash sécurité patient - Posted on Sep 19 2022

Context

Nasogastric tube placement is a common procedure that seems simple on the face of it. However, numerous complications have been reported, primarily associated with the tube penetrating outside the digestive tract.

The most common malpositions concern the tracheobronchial tree, with a frequency of between 0.5 and 11% and risks of pneumothorax, bronchopleural fistula or inhalation of nutrient mixture and/or medicinal products.

Twenty care-related serious adverse events associated with nasogastric tube malpositions have been reported in the HAS national care-related serious adverse event reporting database.

Objectives

By sharing this feedback relative to changing nasogastric tubes, this focus aims to both draw the attention of and raise awareness among healthcare professionals as to the occurrence of serious adverse events that could have been prevented by following best practices during nasogastric tube placement.

So it doesn’t happen again

While this focus highlights failures when changing nasogastric tubes, both in the context of enteral nutrition and suctioning following an obstruction, it also reminds us of good practice guidelines, including the need to systematically check that the tube is correctly positioned.

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