In March 2011 NPSA (National Patient Safety Agency, UK) issued an alert regarding harm caused by misplaced nasogastric feeding tubes.
The most common cause of error (leading to misplacement into the trachea rather than stomach) was misinterpretation of x-rays.
Our agreed policy is :
- pH testing should be used as the 1st line test method (with pH between 1 and 5.5 as the safe range)
- X-ray should only be used as a 2nd line test
- The clinician requesting the x-ray must confirm, on the request, the results of pH testing befor an x-ray will be completed