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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 10/1/2020 12:00:00 AM
Country: Hong Kong

This alert describes a patient safety incident of retention of a foreign body related to insertion and removal of a nasogastric tube (NGT). A patient who required feeding via a NGT was discovered with the NGT coiled in their mouth. The feeding was stopped and the coiled NGT was removed. A new NGT was inserted without documentation on the NGT removal and insertion. Feeding was resumed after confirming the placement by X-ray. About one month later, the NGT was found coiled in patient’s mouth again. The NGT was removed, reinserted and documented. Post-procedure X-ray revealed an abnormal opacity, and the NGT was then removed with X-ray taken. The same radio-opaque line was shown in the X-ray image. Oesophago-gastro-duodenoscopy was performed, and a 35cm long broken silicone NGT segment was found and removed. Contributing factors and recommendations to prevent similar incidents are provided.

Additional Details

nasogastric tube (NGT), Entriflex feeding tube

Retained Instruments / Material – Segment of Silicone Nasogastric Tube