Clinical and Nonclinical Implications of Misplaced Nasogastric Tubes: Tools for Implementation of Standardized Best Practices


  • Olivia Lounsbury Patient Safety Movement Foundation
  • Jennifer Tatro, MSN, RN UCHealth Memorial Hospital Central
  • Beth Lyman, MSN, RN Children’s Mercy Kansas City
  • Donna M. Prosser, DNP, RN Patient Safety Movement Foundation
  • Haylie Coffey, MSN, RN Carolinas HealthCare System Blue Ridge



The consequences of misplaced nasogastric tubes extend far beyond the clinical setting and have implications for the hospital’s reputation and economic stability. A systematic approach for nasogastric tube insertion and verification is necessary in order to prevent misplaced nasogastric tubes which are, indeed, “never events.” The Actionable Patient Safety Solutions (APSS) from the Patient Safety Movement Foundation outline best practices for implementation of nasogastric tube placement protocols in hospitals to ensure consistency across the organization and preserve patient safety at the forefront of all clinical endeavors.

Author Biographies

Olivia Lounsbury, Patient Safety Movement Foundation

Olivia Lounsbury ( is a clin-ical research coordinator for the Patient Safety Movement Foundation.

Jennifer Tatro, MSN, RN, UCHealth Memorial Hospital Central

Jennifer Tatro is the manager of clinical quality and patient safety at UCHealth Memorial Hospital Central in Colorado Springs, Colorado.

Beth Lyman, MSN, RN, Children’s Mercy Kansas City

Beth Lyman is a nutrition support nurse consultant and senior program coordinator of the Nutrition Support Team at Children’s Mercy Kansas City.

Donna M. Prosser, DNP, RN, Patient Safety Movement Foundation

Donna Prosser is the chief clinical officer for the Patient Safety Movement Foundation.

Haylie Coffey, MSN, RN, Carolinas HealthCare System Blue Ridge

Haylie Coffey is director of Patient Safety & Nursing at Carolinas HealthCare System Blue Ridge.


Mira JJ, Lorenzo S, Navarro I. Hospital Reputation and Perceptions of Patient Safety. Med Prin Pract. 2014;23(1):92-94. doi:10.1159/000353152.

Aguilar-Nascimento JED, Kudsk KA. Clinical Costs of Feeding Tube Placement. J Parenter Enteral Nutr. 2007;31(4):269-273. doi:10.1177/0148607107031004269.

Mcwey RE, Curry NS, Schabel SI, Reines HD. Complications of Nasoenteric Feeding Tubes. Am J Surg. 1988;155(2):253-257. doi:10.1016/s0002-9610(88)80708-6.

Baskin WN. Acute Complications Associated With Bedside Placement of Feeding Tubes. Nutr Clin Pract. 2006;21(1):40-55. doi:10.1177/011542650602100140.

Bourgault AM, Halm MA. Feeding Tube Placement in Adults: Safe Verification Method for Blindly Inserted Tubes. Am J Crit Care. 2009;18(1):73-76. doi:10.4037/ajcc2009911.

Wallace S. Data Snapshot: Complications Linked to Iatrogenic Enteral Feeding Tube Misplacements. Pa Patient Saf Advis. 2017.

Rassias A, Ball P, Corwin H. A Prospective Study of Tracheopulmonary Complications Associated With the Placement of Narrow-Bore Enteral Feeding Tubes. Crit Care. 1998;2(1). doi:10.1186/cc120.

Lyman B, Kemper C, Northington L, Yaworski JA, Wilder K, Moore C, Duesing LA, Irving Sharon. Use of Temporary Enteral Access Devices in Hospitalized Neonatal and Pediatric Patients in the United States. J Parenter Enteral Nutr. 2016;40(4):574-580.

Mcfarland A. A Cost Utility Analysis of the Clinical Algorithm for Nasogastric Tube Placement Confirmation in Adult Hospital Patients. J Adv Nurs. 2016;73(1):201-216. doi:10.1111/jan.13103.

Summerford v Abington Memorial Hospital case. CaseMine. Accessed April 13, 2020.

Staff NHLC. Feeding Tube Mishap Results in Patient Death & Large Nursing Home Fine. Nursing Home Law News. Published May 27, 2019. Accessed April 13, 2020.

Patient Safety Movement. Patient Safety Movement. Accessed April 13, 2020.

Metheny NA, Stewart BJ, Mills AC. Blind Insertion of Feeding Tubes in Intensive Care Units: A National Survey. Am J Crit Care. 2012;25(5):352-360.

Parker LA, Withers JH, Talaga E. Comparison of Neonatal Nursing Practices for Determining Feeding Tube Insertion Length and Verifying Gastric Placement With Current Best Practice. Adv Neonat Care. 2018; 18(4):307-317.

AACN Practice Alert. Initial and Ongoing Verification of Feeding Tube Placement in Adults. Crit Care Nurse. 2016;36(2):e8-12.

NHS. Resource Set: Initial Placement Checks for Nasogastric and Orogastric Tubes. NHS Improvement. 2016. Accessed 11 April 2020.

Patient Safety Authority. Misplacements of Enteral Feeding Tubes Increase After Hospitals Switch Brands. Am J Nurs. 2015;115(6):44-46.

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How to Cite

Lounsbury, O., Tatro, J., Lyman, B., Prosser, D., & Coffey, H. (2020). Clinical and Nonclinical Implications of Misplaced Nasogastric Tubes: Tools for Implementation of Standardized Best Practices. Patient Safety, 2(3), 64–67.



Patient Safety Initiatives
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