Safety warnings

The use of enteral feeding tubes to administer food and medication to patients is a complex process. A recent National Patient Safety Agency (NPSA) alert⁵⁹⁷ reported 21 deaths and 79 cases of harm due to misplaced enteral feeding tubes. A 2007 NPSA safety alert⁵⁹⁶ warned against the use of intravenous syringes for the preparation and administration of enteral medication; a process which had caused 33 adverse incidents over a 17 month period. The accidental intravenous administration of medicines intended for oral / enteral use (e.g. phenytoin syrup) has been responsible for causing patient harm, including death in some cases.²³⁰

Below are some of the national recommendations which have been made regarding the use of enteral feeding tubes - please note that the recommendations have been summarised.

National Nurses Nutrition Group: Guidelines for confirming correct positioning of nasogastric feeding tubes, June 2004⁵⁹⁵

Regarding tube position testing:-

Correct tube positioning should be confirmed following initial placement, and before each use.
Radiography should not be used for daily confirmation of tube position due to increased exposure to radiation, cost implications, loss of feeding time and impracticality.
Placing the proximal end of the tube under water and observing for air bubbles is unreliable and should not be used.

NPSA Patient Safety Alert 05: Reducing the harm caused by misplaced nasogastric feeding tubes, February 2005¹²⁰

Regarding tube position testing:-

Measuring the pH of aspirate using pH indicator strips / paper is recommended.
DO NOT use the 'whoosh' test.
DO NOT use blue litmus paper.
DO NOT interpret absence of respiratory distress as an indicator of correct positioning.

NPSA Patient Safety Alert 19: Promoting safer measurement and administration of liquid medicines via oral and other enteral routes, March 2007⁵⁹⁶

Regarding oral / enteral syringes:-

Only use labelled oral / enteral syringes that cannot be connected to intravenous catheters or ports to measure and administer oral liquid medicines.
DO NOT use intravenous syringes to measure and administer oral liquid medicines.

Regarding enteral feeding systems:-

Enteral feeding systems should not contain ports that can be connected to intravenous syringes or that have end connectors that can be connected to intravenous or other parenteral lines.
Enteral feeding systems should be labelled to indicate the route of administration.

NPSA Patient Safety Alert NPSA/2011/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants, March 2011⁵⁹⁷

Placement of a feeding tube should be delayed if there is not sufficient support available to accurately confirm tube placement (e.g. at night), unless clinically urgent.
Nasogastric tubes used for the purpose of feeding should be radio-opaque throughout their length and have externally visible length markings.
pH indicator paper must be CE marked and intended by the manufacturer to test human gastric aspirate.
Nasogastric tubes must not be flushed, nor any liquid / feed introduced through the tube following initial placement, until the tube tip is confirmed, by pH testing or x-ray, to be in the stomach.
pH testing is the first line test method, with pH between 1 and 5.5 as the safe range. Each test and test result should be documented on a chart kept at the patient's bedside.
X-ray should be used only as a second line test when no aspirate can be obtained or pH indicator paper has failed to confirm the position of the nasogastric tube.
Documentation of the tube placement checking process should include confirmation that any x-ray viewed was the most current x-ray for the correct patient, and how placement was interpreted. Any tubes identified to be in the lung must be removed immediately.
A full multidisciplinary supported risk assessment must be made before a patient with a nasogastric tube is discharged from acute care to the community.

ISO 80369-3: 2016 Small-bore connectors for liquids and gases in healthcare applications - Part 3: Connectors for enteral applications

This standard specifies the dimensions and design requirements for small-bore connectors used in enteral medical devices and accessories. It is intended to reduce the harm caused by enteral-IV errors by designing enteral equipment so that it is not compatible with IV equipment and the two cannot be connected together.

The result of this standard being introduced has been the re-design of enteral feeding equipment with �ENFit� connectors. This means that syringes used to administer medication via enteral feeding tubes which meet the new standard must have female reverse luer connectors which conform to the new design.

Safety warnings

National Nurses Nutrition Group: Guidelines for confirming correct positioning of nasogastric feeding tubes, June 2004595

NPSA Patient Safety Alert 05: Reducing the harm caused by misplaced nasogastric feeding tubes, February 2005120

NPSA Patient Safety Alert 19: Promoting safer measurement and administration of liquid medicines via oral and other enteral routes, March 2007596

NPSA Patient Safety Alert NPSA/2011/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants, March 2011597

ISO 80369-3: 2016 Small-bore connectors for liquids and gases in healthcare applications - Part 3: Connectors for enteral applications

National Nurses Nutrition Group: Guidelines for confirming correct positioning of nasogastric feeding tubes, June 2004⁵⁹⁵

NPSA Patient Safety Alert 05: Reducing the harm caused by misplaced nasogastric feeding tubes, February 2005¹²⁰

NPSA Patient Safety Alert 19: Promoting safer measurement and administration of liquid medicines via oral and other enteral routes, March 2007⁵⁹⁶

NPSA Patient Safety Alert NPSA/2011/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants, March 2011⁵⁹⁷