title: Enhancing patient safety during feeding-tube insertion: a review of more than 2,000 insertions.
abstract: BACKGROUND
  An intervention to reduce complications from insertion of small-bore nasogastric feeding tubes was performed.
  
  
  METHODS
  This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding-tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre- and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology-guided insertion, and implementation of explicit policies and procedures.
  
  
  RESULTS
  Of all small-bore nasogastric feeding-tube placements, 1.3%-2.4% resulted in 50 documented cases of feeding-tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding-tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15-month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the "number between" tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project.
  
  
  CONCLUSIONS
  Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.
authors.affiliation: Department of Medicine, Jefferson Medical College and Office of Clinical Affairs, Jefferson University Hospital, Philadelphia, Pennsylvania, USA. rachel.sorokin@jefferson.edu
authors.forename: Rachel
authors.initials: R
authors.lastname: Sorokin
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Gottlieb
mesh_terms: D004750:Enteral Nutrition / Q000295:instrumentation / Q000379:methods / Q000592:standards; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000009:adverse effects / Q000592:standards*; D005791:Patient Care / Q000295:instrumentation / Q000379:methods / Q000592:standards*; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D012449:Safety; D016896:Treatment Outcome