a nasogastric feeding tube
Uncovering a Widespread, Unidentified Supply Issue
​​A facility called the Patient Safety Authority with a concern regarding misplacements of nasogastric feeding tubes. Several veteran staff members were suddenly inserting them in patients’ lungs instead of their gastrointestinal tract, and the facility wanted to know if anyone else had reported the same issue. Through a review of the Pennsylvania Patient Safety Reporting System (PA-PSRS), the PSA was able to identify that two other facilities had reported similar scenarios, assist in determining the root cause, and alert others about the issue.

Further investigation revealed that a popular manufacturer had stopped producing the enteral devices, forcing facilities to find an alternative quickly. This facility had ordered a replacement of the same size and type, but communication of the change did not reach frontline staff who were placing the feeding tubes. The staff continued to place the tubes as they always had—without knowing they were using a different product. Once the staff became aware of the change, they commented that the new tubes seemed less pliable and slicker than the previous ones.​