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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 4/1/2020 12:00:00 AM
Country: Hong Kong
This alert describes an incident of retained foreign body of a tip of a feeding tube. An old age home (OAH) resident with a history of stroke required nasogastric tube feeding and was supported by the Community Nursing Service. During this time, there were multiple admissions emergent care presentations to more than one hospital. When the patient was suspected of swallowing a piece of gauze, the silicone nasogastric tube was removed to facilitate assessment. The tip was checked and documented to be intact. Subsequent abdominal X-ray revealed a linear opacity at the stomach region. Oesophagogastroduodenoscopy was performed and a segment of nasogastric tube was found in the stomach. A suggestion for preventing similar incidents is provided along with contributing factors for this incident.

Additional Details

Device:
silicone nasogastric tube

Rules / Policies / Procedures
  1. Enhance documentation, including the completeness of removed nasogastric tube.

Retained Instruments / Material -- Segment of Nasogastric Tube