Improper Placement of Nasogastric Tube Leads to Patient Death

Case Overview

This cardiac radiology case involves a female patient who suffered from acid reflux and had used heartburn medication in the past, was admitted into the ER and diagnosed with a small bowel obstruction in Arizona. She had a nasogastric tube placed for decompression of her stomach and placement was checked by stethoscope. Following the placement, an x-ray was taken which showed that the feeding tube seemed to extend into the patient’s lungs. This was discussed with the patient’s nurse. The patient was then transported to the interventional radiology department in order to have the nasogastric tube placed again. While in the interventional radiology department a code blue was called. After the procedure was completed, the patient was noted to look unwell, and then became unresponsive. The patient suffered a cardiac arrest following the placement of the new tube, and eventually passed away.

Questions to the Nursing expert and their responses

Do you routinely care for patients like the one described above?

As a Director of Nursing and a staff nurse in the Emergency Department, I have worked with placement of nasogastric tubes many times.

What is the nursing protocol to place and use a nasogastric tube?

Here is one protocol described in greater detail: Measure tube from tip of nose to subxyphoid process. Gather a cup of water with a straw. Wash hands and don gloves. Check the physician order for size of tube and amount of suction to be applied. Prep the nose for the later taping the tube in place. Insert the tube while asking the patient to swallow water via the straw. Stop at 35mm to make sure you're not in the bronchus (via chest x-ray). When confirmed, continue into the stomach. Check placement by inserting air into the stomach and confirm with an abdominal x-ray.

About the expert

This highly experienced director of nursing for a 180 bed skilled nursing, assisted living and independent living community has over ten years of experience as a multi-state regional nurse manager. Her current position involves supervision of 150 team members to include the physicians, nurse team, floor nurses, social workers, infection control, quality assurance, medical records, a commissary and recreation therapy. She spent three years as a clinical nurse specialist. She is a registered and certified nursing home surveyor. She spent many years as a regional nurse consultant and recently received a Medicare/Medicaid deficiency free survey.

E-007898

Specialties:

Nursing