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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

Device:
nasogastric tube (NGT), Entriflex feeding tube

Rules / Policies / Procedures
  1. Strengthen the practice of checking integrity, especially the presence of the tip of the NGT upon removal.
  2. Align the practice of documentation for NGT insertion and removal, with compliance monitored.

Retained Instruments / Material – Segment of Silicone Nasogastric Tube