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.