Nasogastric Tube ( NGT ) and On-going Care for Adults - Guidelines for the Insertion of a
|Publication: 01/10/2002 --|
|Last review: 27/07/2021|
|Next review: 02/10/2022|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2021|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guidelines for the Insertion of a Nasogastric Tube (NGT) and Ongoing Care for Adults
- Criteria for Competence, Accountability and Responsibility
- Procedure for Confirmation of NGT position in the stomach
- Nurses responsibility after x-ray
- Advancing partially displaced tubes
- Discrepancy in external length
- Appendix 1 – Selection and Care of NGT
- Appendix 2 - Passing the nasogastric tube (NGT)
- Appendix 3 - Ongoing Care of NGT
- Appendix 4: Care plan - Care of Adults with Nasogastric Feeding Tubes (NGTs) - LTH2941
- Appendix 5: Decision Tree for NGT position checking on insertion
- Appendix 6: Decision Tree for NGT position checking for ongoing care
- Appendix 7 - NGT Insertion competency for Registered Nursing Staff/Trainee/Advanced Clinical Practitioners (ACPs)/Physician Associates (PA)
- Appendix 8 - Criteria for assessment of competence for insertion of Nasogastric Tubes for Adult Patients and/or Carers
- Appendix 9 - Physiotherapists Disconnection of Enteral Feeding Tubes competency assessment
- Appendix 10 - NGT On-going Care competency for Registered Nursing Staff and Band 4 Nursing Associates (NAs) Trainee/Advanced Clinical Practitioners (T/ACP) and Physician Associates (PA)
- Appendix 11 - NGT On-going Care competency for Band 4 Assistant Practitioners
Placement of nasogastric tubes (NGTs) is common practice and thousands of NGTs are inserted daily without incident. However, there is a risk that the NGT can become misplaced into the lungs during insertion, or move out of the stomach at a later stage (NPSA, 2005, NPSA, 2011).
These guidelines have been produced to support staff in the correct insertion and on-going care of a NGT.
This guideline relates to NGTs which are used for:
- Artificial feeding, in an adult who is unable to eat and drink sufficient to maintain nutritional status.
- Artificial feeding and hydration, in an adult who has an unsafe swallow
In 2009 feeding into the lung from a misplaced NGT became a “Never Event” in England (NPSA, 2010).
Insertion of NGTs is common practice and thousands of NGTs are inserted daily without incident. However, there is a risk that the NGT can become misplaced into the lungs during insertion, or move out of the stomach at a later stage, i.e. Become displaced (NPSA, 2005, NPSA, 2011).
A misplaced NGT is now a “Never Event” (NPSA, 2010) and in March 2011 the NPSA gave additional guidance regarding NGT placement and ongoing care.
Professionals undertaking this procedure may be :
- Registered nurses
- Registered medical staff
- Physician associates (PA)
- Advanced clinical practitioners (ACP)
- Band 4 Assistant Practitioners (on-going care only)
- Nurse Associates (registered) (on-going care only)
Physiotherapists in designated areas who have undergone the appropriate training and competency assessment (Appendix 9 ) can be involved in the disconnection of NGTs from giving sets for the purpose of undertaking therapy sessions.
The professional must have undertaken the relevant training package as outlined on their individual Mandatory and Priority Training Interface. The number of supervised practices required to achieve competence will be determined by the practitioner and supervisor, taking into account the practitioner’s own learning needs.
Assistant Practitioners and Nurse Associates will only provide on-going care and work within their scope of practice. If they obtain an aspirate of above pH 5 this must be referred to a Band 5 (or above) registered nurse for them to undertake a risk assessment as discussed in ‘Procedure for Confirmation of NGT position in the stomach’.
If an assistant practitioner/nurse associate obtains a pH value of 5, their second checker must be a Band 5 (or above) registered nurse.
Assistant practitioners must also double check the feed bag with either a nurse associate or a Band 5 (or above) registered nurse, in order for this to be recorded on E-meds.
Clinical areas need to ensure that they have a registered list of enteral feed that assistant practitioners can administer as per the ‘Administration of medicines by Unregistered Practitioners procedure’
Nurse Associates can administer medicines and enteral feeds as per policy (expected approval December 2018).
Patients and other carers e.g. relatives or other individuals involved in the patient’s daily care should be trained by a recognised practitioner, who is competent in the ongoing care of NGTs. Any patients or carers for whom it is deemed necessary to insert NGTs should be deemed competent to do so using the ‘Insertion of Nasogastric Tubes for Adult Patients and/or Carers Competency Framework’ (Appendix 8).
Nurses and medical staff in training can undertake the procedure under the supervision of a recognised practitioner who is competent in the insertion of NGT.
The Insertion and On-going care of NGTs are priority training topics, and you mustensure you have satisfied your training requirements by reviewing the LTHT Mandatory Training Interface.
Any practitioner reviewing an x-ray must have completed ‘The Guidelines for the Insertion of the Nasogastric Tube (NGT) and On-going care for Adults’ e-learning package which is accessible on the LTHT Mandatory Training Interface. Their certificate giving evidence of successful completion should be available for review if required and kept within their training file
Evidence of continuing professional development and maintenance of skill level will be required.
The practitioner must accept accountability for their own practice.
Consent for the procedure should be sought under the guidance of the Trust’s consent policy.
The consent process should involve discussion with the patient about not only the risks of the insertion of the NGT, but also on-going feeding, such as the potential risks of aspiration if the recommended angle for feeding is not maintained, or if the patient tampers with the tube.
Decision making and timing of insertion
Before a decision is made to insert a NGT, an assessment should be undertaken to identify if NGT feeding is appropriate for the patient, and the rationale for any decision recorded in the patient’s medical notes (NICE, 2006). This may require a thorough review of the ethical dimension to care in some cases and requires the input of two trained healthcare staff, one of whom should be the Senior Doctor responsible for the patient’s care. Decision making should include consideration of the practical and safety aspects of on-going feeding via a NGT. For example, patients who are confused, unlikely to be able to independently maintain a safe position for feeding, or situated in a side room or away from the central ward area, will need further consideration. It may be appropriate to move the patient to a more visible bed space and ensure they are only fed during day time hours, where there is likely to be more staff available to observe the patient. This risk assessment should be clearly documented by the managing medical team, and recommendations clearly communicated to Dietetic and Nursing staff.
As a minimum, documentation should include a signed, dated and timed entry, where the risks and benefits of NGT are clearly evaluated (NPSA, 2011).
NGTs should only be inserted if suitably trained and experienced staff are available for the procedure to be safely completed. Outside the critical care setting it is rare for a feeding NGT to be essential after 22.00 hours and this is usually for medication which cannot be given by another route. All efforts should be made to administer the medication via an alternative route if this will negate the need for the insertion of a nasogastric tube out of hours. Clinical staff should arrange to insert a NGT for feeding during day time working hours and document this. Feeding should not be initiated out of hours. If insertion is delayed for any reason and the patient is nil by mouth, ensure fluids are given by intravenous or subcutaneous route.
There may be increased risks associated with NGT insertion for some patients. Further discussion with senior members of the medical team should take place. Some patients may need NGTs placing under fluoroscopic or endoscopic control:
- Maxillo facial surgery / trauma / disease
- Oesophageal tumours / strictures / fistulae / surgery
- Pharyngeal pouch
- Skull fractures
- Large hiatus hernia / severe gastro-oesophageal reflux
- Oesophageal varices (not completely contraindicated, but needs discussion)
- Patients with a low GCS, due to risk of aspiration
Type of nasogastric tube
NGTs must be radio opaque and have markings in one cm increments along the length of the tube. NGTs are available in a number of sizes and lengths. The most commonly used size of NGT for feeding is 8 French gauge (Fr). This relates to the external diameter of the tube. NGTs are available in various lengths from 85-120 cm. Appendix 1 shows how to measure the estimated length of NGT to be passed for gastric placement. The NEX (nose-ear-xiphisternum measurement, in cm) is an estimate of the NGT length required, and should be measured before insertion. However the minimum length of insertion should be 55 cm.
Wide bore (Ryles type tubes) and short term NGTs are usually made from Polyvinylchloride (PVC) and should only be in-situ for 7-10 days maximum due to a tendency for the plasticisers to leach out in reaction with gastric juices. This causes the tube to become brittle, increasing the risk of gastric erosion and ulceration (Dewar, 2003) Wide bore tubes are not licensed for enteral feeding and should not be used for this use.
Fine bore (≤10Fr) polyurethane tubes overcome the above problems and the tubes have a guide wire inside to assist placements. Please refer to manufacturer’s guidelines for the length of time a feeding tube can stay in-situ.
All NGTs are available from NHS Supplies.
The guide wire should be removed immediately after placement of NGT, to facilitate comfort and obtaining gastric aspirate. The guidewire should never be re-inserted whilst the tube is in the patient.
If the NGT meets resistance and cannot be advanced further, the procedure should be abandoned, the patient reassured and referral made to a more experienced practitioner.
In the case of respiratory distress the NGT should be immediately withdrawn, the patient reassured and referral made to a more experienced practitioner.
Please note that the absence of respiratory distress during the insertion of the tube should not be used as an indicator that the tube has been correctly inserted into the stomach (NPSA 2005)
It is crucial to differentiate between gastric and respiratory placement to prevent potentially catastrophic pulmonary complications. Since the September 2005 NPSA Alert, Reducing the harm caused by misplaced NGT, the NPSA has become aware of 21 deaths and 79 other cases of harm due to feeding into the respiratory tract through misplaced NGTs. In 45 per cent of cases the harm was due to misinterpreted x-rays (NPSA, 2011).
NGT Position Checks
NGT position should be checked by aspirating material with pH 1-5 or confirmation by x-ray:
- On insertion
- Following vomiting / retching/nasopharyngeal suction / violent coughing
- Following evidence of tube displacement
Ongoing position checks by aspiration or checking NGT external length (Appendix 1) should occur:
- After transfer of patient from another clinical area.*
- Before each bolus feed/drug administration
- At least once every 12 hours during continuous feeding
*N:B The feed should be stopped and disconnected from the NGT on transfer of the patient from one clinical area to another. This is because the risk of accidental misplacement of the tube or the patient getting into a suboptimal position may be greater during transfer
Where a patient has a Nasal Retaining Loop (NRL/ ‘bridle’) Device in place, the external length should also be recorded before and after any manipulation of the device to ensure the position of the tube has not moved.
Bedside methods of confirming NGT placement
pH testing is used as the first line test method, with pH between 1 and 5.0 as the safe range. Each test and test result must be documented on the ‘Care for Adults with Nasogastric Feeding Tubes (NGTs)’ care plan (WUN1114) and should be kept at the patient’s bedside.
The documentation must include:
- whether aspirate was obtained;
- what the aspirate pH was;
- who checked the aspirate pH;
- pH readings should be between 1 and 5.0 for feeding to commence safely.
- All areas where NGT placement is likely to occur must have access to pH paper that is licenced and CE marked, approved by supplies and intended by the manufacturer to test human gastric acid
- All pH tests and test results must be recorded on the ‘Care for Adults with Nasogastric Feeding Tubes (NGTs)’ care plan and should be kept at the patient’s bedside.
pH readings should be between 1 and 5 for feeding to commence safely. However, there may be difficulty in differentiating pH readings of pH 5 and 6. It is therefore recommended that a second competent person checks any readings of pH 5, to confirm the result.
On the initial insertion of the tube, if there is any uncertainty about the interpretation of the pH paper, despite a second checker, a check x-ray must be performed.
(See LTHT NGT Care Plan-Appendix 4)
A sensitive acid indicator such as pH paper or sticks should be used (NPSA, 2005, NPSA, 2011). Litmus paper is not sufficiently accurate to distinguish between gastric aspirate pH<5, and bronchial secretions pH>6 and therefore must not be used in any circumstance.
Auscultation of the epigastrium or left upper quadrant whilst air is insufflated via the tube (whoosh test) is not able to reliably predict tube placement in the oesophagus, stomach or respiratory tract and must not be used (NPSA, 2005, NPSA, 2011).
It must be noted that the withdrawal of blood or blood-stained aspirate could be a sign of tube misplacement in the lung. Blood may give the inserter a false positive aspirate, as blood will stain pH paper red, which could appear to be pH 1. Where there is any concern that the aspirate could be blood, a check x-ray should be requested to confirm the position of the tube.
Red Flag Indicators of Tube Misplacement
The tube may not be correctly positioned if:
- There was difficulty during the insertion procedure
- No aspirate has been obtained
- New changes on x-ray (i.e pneumothorax)
- Blood-stained fluid is aspirated
Always seek senior medical advice if you have any concerns about confirming tube position
- proton pump inhibitors
- H2 antagonists
Where feed/medication has already passed through the tube, a minimum of an hour delay, without any further feeding, should be instigated prior to testing of gastric aspirate using the correct pH paper wherever aspirate can be obtained. However, in some situations, such as when patients are fed continuously, when they are treated with acid-reducing medication and when medications are frequently given down nasogastric tubes, it may not be possible to obtain aspirate with a pH between 1 and 5, and daily x-rays are not practical or safe.
Therefore, in circumstances where the initial placement was appropriately confirmed, and there is no reason to suspect displacement since (i.e. no vomiting, retching or coughing spasms and no unexplained respiratory symptoms) the only practical method of determining if the tube remains correctly placed prior to each administration of medications or feed may be through external observation of the tube.
In this case, an individual risk assessment involving the nursing and medical staff should be carried out for each patient. This decision should be clearly documented in the patient’s medical notes or bedside care plan. It should include confirmation that the length of the external tube remains identical to that recorded initially and that fixation tapes or plasters have not moved or worked loose.
Please note, if there is evidence that the tube has become displaced, for whatever reason, then only checking the external length would be inappropriate as it could be coiled in the back of the mouth, so in this circumstance second line testing through x-ray, or removal of the tube if seen to be coiled in the mouth, would be appropriate.
Radiological confirmation of NGT position
Radiological confirmation of NGT position is costly, disruptive for patients and staff and frequently results in lost feeding time and missed medication (DoH 2007) Its safety is also dependent on the x-ray being read by appropriately trained staff (NPSA 2011). Therefore x-rays should only be performed when necessary as outlined in these guidelines. If required, an authorised referrer should request the X-ray on ICE selecting ‘NG Tube Check’. The referrer must answer all the clinical questions regarding the patient in order for the Radiographer to proceed with imaging.
(NB: if a check x-ray is required during a feed, the feeding tube must be disconnected from the giving set, until the position of the tip of the tube has been confirmed as outlined below. This is to prevent inadvertent administration of feed via a potentially misplaced tube)
- Aim of the plain film is to confirm the position of the NGT.
- A diagnostic x-ray must be produced which proves the tip of NGT lies below the diaphragm.
- Ensure that exposure of the x-ray is adjusted to allow the NGT to be visible.
- Ensure the x-ray is centred lower than would normally be appropriate for a chest x-ray so that it shows the upper abdomen (i.e. below the diaphragm).
- It is not necessary to repeat the x-ray for clipped apices / missing costophrenic angle unless this affects the view of the NGT or the X-ray is requested for additional clinical reasons.
- It is essential that a diagnostic radiograph of the position of the NGT is obtained before the examination is completed.
- Apply a sticker to the NGT to identify to the ward staff that an X-ray has been performed. The sticker is there to inform ward staff to check the X-ray prior to using the NGT in order to prevent a never event
- This is not an x-ray of the lungs. If a formal CXR is required to assess the whole lungs this must be stated explicitly on the request card.
- The final radiograph must clearly state the time it was taken, that it is for an NGT check and any non-average exposure factors.
- The radiographer must provide a comment of the position of the NGT. This comment will be visible on PACS.
- The radiographer must contact the clinical team on the ward if it is recognised that the NGT is not in the correct position. The radiographer must record on CRIS the staff members name of this communication.
- This is not a final clinical interpretation. All examinations still require evaluation by the trained member of the ward team (Doctor/ACP/PA) and will have a final report issued by a Radiologist (see below).
- Departmental x-rays:
- Radiographers will remove any tubes placed in the lung or coiled in the oesophagus
- Radiographers will contact the ward to request a member of staff come to the x-ray department to advance any tubes where the tip is pointing down in the oesophagus or is in the stomach but is not 5cm below the diaphragm
- Portable x-rays:
- If the tube needs to be removed or advanced the radiographer will contact the ward and inform a member of staff
- For documentation purposes the name of the ward staff taking this message will be asked for by the radiographer.
Responsibility of doctor/PA/ACP reviewing the X-ray
- Any practitioner reviewing an x-ray must have completed ‘The Guidelines for the Insertion of the Nasogastric Tube (NGT) and On-going care for Adults’ E-Learning package which is accessible on the LTHT Mandatory Training Interface.
- It is essential that the most recent x-ray is reviewed, and that the date and time of this x-ray are documented.(see LTHT Care plan - Appendix 4)
- The doctor/PA/ACP should record that the tube is in a satisfactory, safe position for feeding.. The doctor/PA/ACP should confirm that the tube:
- Follows the oesophagus
- AND bisects the carina
- AND crosses the diaphragm in the midline
- AND passes at least 5cm below the diaphragm (see LTHT Care plan - Appendix 4)
- By checking the radiographer comment and the x-ray on PACS.
- If the tube can be seen to follow the normal anatomical course of the oesophagus into the abdomen below the diaphragm it can be assumed this lies within the stomach. If the tip of the tube cannot be seen as it passes off the bottom of the film it can be left in position and no further films are required. The tube should not be pulled back, but can be used safely if it is beyond the pylorus. If any doubt exists, this should be discussed with a radiologist immediately and before tube use or repositioning.
- If there is any doubt as to whether the NGT is in a safe position, the ward doctor/PA/ACP MUST discuss with radiology to get a formal report prior to feeding
- The doctor/PA/ACP who checks the x-ray is responsible for communicating and documenting the x-ray result and whether or not the sticker can be removed from the end of the NG tube.
If a radiologist is asked to report an NG tube check x-ray they must describe
- The position of the NGT and tip (when visible).
- Comment that the tube is in a satisfactory position for feeding (accepting that the feeding port of the tube is approximately 1 cm proximal to the tip, so if the tip is at / just beyond the gastro-oesophageal junction, the NGT may need to be advanced)
Where the tube is incorrectly positioned, the radiologist must ensure that the clinical team are aware of this, by telephoning the ward at the time of reporting or ensuring the radiographer who performed the x-ray has done so.
Where an inadequate x-ray has been performed (when tube position below the diaphragm cannot be confirmed) to notify the ward by telephone to arrange an additional x-ray.
Tips and tricks for x-ray interpretation
This section gives a brief overview of common perceptual errors with check NGT x-ray interpretations. The examples given are all taken from LTHT incident report (Incident form) forms and consist of common issues that the radiology departments deal with when dealing with check NGT x-rays.
Common interpretation errors:
- I think the tube is in ‘too far’
- I think the tube is ‘not in far enough’
- I must see the tip of the tube
1. I think the tube is in ‘too far’. The following three examples demonstrate the tip of the tube to be below the diaphragm. The tips of these tubes sit in the distal stomach. This is evident from the path the tube takes (passes below the diaphragm and deviates to the left) and the length of tube that lies below the diaphragm. Do not adjust these tubes. ALL OF THESE TUBES ARE SAFE TO FEED THROUGH. If the tip of the tube is in the small bowel it is still safe to feed.
2. I think the tube is ‘not in far enough’. The following examples show the tip of the tube to be coiled in the fundus. These NG tubes were manipulated by ward staff who thought it was not far enough in to the stomach. This misinterpretation led to delays in the patients commencing their feed. As long as the tip of the tube is at least 5cm below the diaphragm it is safe to use. THE POSITION OF THE TUBE IN ALL OF THESE X-RAYS IS ADEQUATE FOR FEEDING.
3. I must see the tip of the tube. It is not necessary to see the tip of the NGT as long as you can see it pass at least 5cm below the diaphragm. The following examples all demonstrate the tip of the NGT to be below the diaphragm. You cannot see the tip on any of these x-rays but you can see the tube pass below the diaphragm. ALL OF THESE TUBES ARE SAFE TO FEED THROUGH.
When a patient has had an x-ray the nurse, assistant practitioner or nurse associate must ensure that the responsible doctor/PA/ACP has reviewed the x-ray and confirmed and documented that it is in a safe position for feeding. It will be communicated that the sticker placed on the tube by the Radiographer can be safely removed. Before using the tube the nurse, assistant practitioner or nurse associate must re-check the external length of the tube and confirm there is no reason to suspect displacement since the x-ray was taken (i.e no coughing spasms, retching, vomiting).
If there is any suspicion the tube may have been displaced since confirmation of position by x-ray, further position checking by pH testing of gastric aspirate (first line test) or repeat x-ray must be performed in order for feed/flush or medication to be administered safely.
Alternative methods of confirmation
Occasionally a patient may be required to undergo radiological investigations associated with their other health needs. These tests can coincide with NGT placement and rather than send the patient for an additional x-ray, the confirmation of position can be confirmed by other radiological investigations such as CT or MRI. Discussion with the consultant radiologist should be sought in order to confirm position of the NGT if using an alternative radiological approach.
The care plan for Care of Adults with Nasogastric Feeding Tubes should be completed (Appendix 4).
NGT insertion - the following should be recorded:
- Reason for insertion and the two staff who made decision (medical notes)
- Confirm procedure explained and consent obtained. If patient lacks capacity should be discussed with proxy decision maker (medical notes)
- Name of professional inserting NGT
- Time and date of insertion
- Type and size of NGT (NGT Care plan - Appendix 4)
- NEX length (Appendix 1 ) (NGT Care plan - Appendix 4)
- Nostril used (right or left) (NGT Care plan - Appendix 4)
- External length of NGT in cm (distance from nose to end of tube not including the cap- Appendix 4)
- Method of confirmation of position (this should include confirmation that aspiration was attempted, and if unsuccessful / pH>5, that the correct X-ray has been checked(NGT Care plan - Appendix 4)
NGT ongoing care – the following should be recorded (see Appendix 4):
- Date and time
- Reason for tube check
- pH aspirate (if possible)
- External tube length
- Action Taken
- Signature of staff member performing checks
To prevent a patient having to undergo further NGT insertion, it may be appropriate to advance a partially displaced tube. This must only be carried out by a practitioner competent in NGT insertion. The practitioner must discard the first aspirate, as to avoid aspiration of residual content from within the tube. The aspirate must be easy to attain and be between pH 1-5 before any liquid is introduced down the tube.
In circumstances where a partial displacement has happened mid- feed, or within an hour of any liquid being administered down the NGT, a minimum of an hour should be observed prior to confirming tube position with pH testing as outlined above. If there is any doubt about the position of the NGT an x-ray must be carried out to confirm the tube has been successfully advanced into the stomach.
If a discrepancy in external length is noted prior to administering liquid via the NGT, the practitioner should confirm tube position using pH testing as the first line check. If this is inconclusive, an x-ray must be requested to confirm the tip of the tube still lies in the stomach.
Adult requiring NGT medication, hydration and/or feeding
|Target patient group:||Adults requiring NGT|
|Target professional group(s):||Secondary Care Nurses
Allied Health Professionals
Secondary Care Doctors
Registered Nurses Working in Critical Care
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
- DEWAR, H. 2003. Nasogastric tube audit: standard setting and review of specifications. Journal of Human Nutrition and Dietetics, 10, 313-315.
- DOH 2007. The Ionising Radiation (Medical Exposure) Regulations. In: DOH (ed.). United Kingdom.
- DURAI R, V. R., NG PC, 2009a. Nasogastric tubes. 1: Insertion technique and confirming the correct position. Nurs Times., 16, 12-3.
- DURAI R, V. R., NG PC. 2009b. Nasogastric tubes. 2: Risks and guidance on avoiding and dealing with complications. Nurs Times., 17, 14-6.
- LISA D, S. L. 2011. Royal Marsden Hospital Manual of Clinical Nursing Procedures, UK, Wiley-Blackwell.
- METHENY NA, S. B. 2002. Testing feeding tube placement during continuous tube feedings. Appl Nurs Res., 4, 254-8.
- NICE 2006. Nutrition support in adults oral nutrition support, enteral tube feeding and parenteral nutrition. In: NICE (ed.) CG32 ed. UK: National Collaborating Centre for Acute Care.
- NICE 2012. Infection: Prevention and control of healthcare-associated infections in primary and community care. In: NICE (ed.) CG139 ed. UK.
- NIGHTINGALE J 2001. Intestinal Failure, Greenwich Medical Media.
- NPSA 2005. Patient Safety Alert: Reducing harm caused by the misplacement of nasogastric feeding tubes. In: NPSA (ed.) 0180 ed. UK.
- NPSA 2010. Never Events Annual Report 2009/10. In: NPSA (ed.) 1281 ed.
- NPSA 2011. Patient Safety Alert: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. In: NPSA (ed.) NPSA/2011/PSA002 ed.
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