Intended for healthcare professionals

Practice Safety Alerts

Checking placement of nasogastric feeding tubes in adults (interpretation of x ray images): summary of a safety report from the National Patient Safety Agency

BMJ 2011; 342 doi: (Published 05 May 2011) Cite this as: BMJ 2011;342:d2586
  1. Tara Lamont, special adviser1,
  2. Catherine Beaumont, head of patient safety1,
  3. Alan Fayaz, specialist trainee in anaesthesia and intensive care2,
  4. Frances Healey, joint head of patient safety (response)1,
  5. Tanya Huehns, head of patient safety (strategy)1,
  6. Robert Law, consultant gastrointestinal radiographer3,
  7. Caroline Lecko, clinical lead (nutrition)1,
  8. Sukhmeet Panesar, clinical adviser (surgery)1,
  9. Michael Surkitt-Parr, joint head of patient safety (response)1,
  10. Mike Stroud, consultant gastroenterologist4,
  11. Bruce Warner, associate director of patient safety1
  1. 1National Patient Safety Agency, London W1T 5HD, UK
  2. 2London Deanery, London WC1B 5DN
  3. 3North Bristol NHS Trust, Bristol BS16 1LE, UK
  4. 4Southampton General Hospital, Southampton SO16 6YD, UK
  1. Correspondence to: T Lamont tara.lamont{at}

Nasogastric feeding tubes are commonly used for people such as stroke patients with dysphagia or those on ventilators. They are generally used in the short to medium term (up to six weeks),1 rather than for longer term feeding, which occurs via gastrostomy tubes, jejunostomies, or gastrostomy buttons.2 Although feeding by nasogastric tubes is not routinely captured in activity data, about 170 000 tubes are supplied to the NHS each year.3 Most are inserted safely, but patients can be harmed if the tube is mistakenly inserted into the lungs or later becomes displaced from the stomach. If such errors are not detected before feeding, patients can develop serious complications, such as intrapulmonary feeding and aspiration pneumonia, which can be fatal. The position of tubes should therefore always be checked before feeding is started.

The National Patient Safety Agency (NPSA) issued guidance in 2005 for safe placement and position checking of nasogastric tubes.3 The guidance highlighted the unreliability of certain tests—such as the “whoosh” test (listening for bubbling sounds after air entry) and testing for acidity with litmus paper—and instead recommended testing with pH indicator paper as the first line check. It recommended checking x ray images as the second line test, although not for routine use. Since 2005, staff in England and Wales have reported 21 deaths and 79 cases of harm resulting from feeding into the lungs through misplaced nasogastric tubes. The single greatest cause of harm resulted from misinterpretation of x ray images, which accounted for 45 serious incidents, including 12 deaths. The NPSA therefore issued a further safety alert in March 2011 focusing on safe interpretation of x ray images.4 The guidance covers adults and children (not neonates), but this short article, based on the March safety alert, summarises advice for adults only.

A …

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