Single or Multiple Incident:
10/1/2020 12:00:00 AM
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.
nasogastric tube (NGT),
Entriflex feeding tube
Retained Instruments / Material – Segment of Silicone Nasogastric Tube