The National Patient Safety Agency has repeated a warning on the risk of harm posed by flushing nasogastric tubes before confirmation of placement.
The rapid response report said nothing should be introduced down the tube before gastric placement has been confirmed; nurses must not flush the tube before gastric placement has been confirmed; and internal guidewires or stylets should not be lubricated before placement confirmation.
It follows a patient safety alert issued by the NPSA in March 2011 about reducing harm caused by misplaced nasogastric tubes. It required trusts to ensure tubes were not flushed nor liquid introduced until the tube tip was confirmed to be in the stomach by pH testing or x-ray.
However, the NPSA said it was aware of three incidents, two of which resulted in death, since the alert went out where staff had flushed tubes with water before initial placement was confirmed.
It said: “The three organisations where the incidents occurred were aware of the NPSA alert but there appeared to be a widespread belief among their frontline staff that the ‘never flush’ rule did not apply where nasogastric tubes had a water-activated lubricant. This belief is incorrect.”