Avoiding never events: improving nasogastric intubation practice and standards.

Aim: To identify and rectify weaknesses in nasogastric (NG) intubation practice in the North Bristol NHS Trust that resulted in the occurrence of a National patient Safety Agency defined "never event".

Material And Methods: Root-cause analysis identified that a change in culture was required. Recommendations divided into four categories: documentation, intubation, interpretation training, and radiology.

Nasogastric tube placement: changing culture.

The Department of Health recognises that feeding through a misplaced nasogastric feeding tube is largely preventable if appropriate steps are taken, and lists it as a never event. After one such never event at a trust, a team of senior clinical staff, senior nursing staff, radiographers, dietitians and medical educational staff were involved in tackling the causes of the problem. This article discusses the steps they took to change trust culture to make placing nasogastric feeding tubes a safer procedure.