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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 a patient safety incident of a nasogastric tube that was inadvertently placed in the lung. An alcohol dependence syndrome patient had desaturation after breakfast one day and was transferred to another hospital for the management of aspiration pneumonia. Speech therapist recommended non-oral feeding in view of dysphagia and risk of aspiration. Milk feeding commenced after the nasogastric tube (NGT) was inserted and its position was checked. The patient pulled out the NGT twice and new ones were re-inserted. As aspirate could not be obtained for acidity testing after the third NGT re-insertion, chest X-ray (CXR) was taken and it was perceived that the NGT was in-situ and feeding could be resumed. Later aspirates were obtained from the NGT and both were acidic (pH=4). Patient developed cardiac arrest later that morning. After 10 minutes of resuscitation, spontaneous circulation was returned. The CXR taken after the third NGT re-insertion was reviewed, and the NGT was found to be misplaced to the LEFT lung. Patient succumbed two days later despite maximal support. Contributing factors and recommendations to prevent similar incidents are provided in the alert.

Additional Details

nasogastric tube (NGT)
vitamin B1, thiamine

Misplaced Nasogastric Tube