Patient Outreach Network Version

Read about safe and effective enteral feeding that optimizes nutritional support while minimizing risks to patients. Also in this issue: announcing our 2026 I AM Patient Safety awards contest winners, a new webinar on reducing workplace violence, and more.

Please share this information with your contacts to ensure everyone has the knowledge and tools to help keep safe.

Enteral Feeding Safety: Protecting Patients While Meeting Nutritional Needs

Ensuring patients with acute and chronic illnesses maintain appropriate nutrition is a critical component of patient care.^1-4 Malnutrition in hospitalized patients is associated with adverse outcomes such as impaired wound healing, prolonged hospital stays, and poorer overall quality of care.^1,2 During many disease processes, receiving adequate nutrition by eating and drinking can be challenging. When oral intake is insufficient, providing patients with nourishment (calories, macronutrients and micronutrients, and fluids) via an enteral route like a nasogastric (NG) tube or other similar mechanisms can help to improve a patient’s nutritional status,¹ positively contributing to the patient’s care and treatment plan.¹

While enteral feeding offers significant benefits to patients, it is a complex process and can present patient safety risks.^5-7 The amount and rate of enteral nutrition must be individualized for each patient according to their nutritional and fluid needs.⁶ Feeding infusions can be administered continuously or intermittently (e.g., bolus feeding). Common risks associated with enteral feeding include feeding intolerance,⁶ aspiration,^5-7 and refeeding syndrome.⁶

A recent review of serious events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) identified two patient deaths related to feeding tube complications involving feeding rate and patient positioning during bolus administration. One patient receiving enteral nutrition via an NG tube was given a feed at an incorrect rate, which led to hypoxia. A second patient administered a bolus feed via their percutaneous endoscopic gastrostomy tube while lying flat, resulting in aspiration.

Both feeding rate and patient positioning are imperative to safe administration of enteral feeds. As mentioned above, the rate of each feed is carefully calculated for each patient.⁶If a feeding is set to a rate that is too fast, the patient is at increased risk of hypoxia from gastric and/or aspiration^.⁶If a feeding rate is too slow for a prolonged period of time, malnutrition can result. Patients are also at an increased risk of spiration when enteral feeds are administered while they are lying flat^.^5-7 During an enteral feeding, the backrest of a patient’s bed should be elevated 30–45 degrees to mitigate aspiration risk.^5-7 If this degree of elevation is not feasible due to other medical issues, the backrest should be elevated as much as possible and the time the patient is lying flat on their back should be limited.⁶

Other strategies to mitigate the risks associated with enteral feedings include:

Observe patients for clinical signs of feeding intolerance, such as gastric distention, abdominal discomfort, diarrhea, nausea, reflux of feeds, and vomiting⁶
Monitor electrolyte levels daily until these levels are stable⁶
Observe patients for signs of “dumping syndrome” such as sweating, tachycardia, and diarrhea, and adjust the feeding rate or formula to address this issue¹
Consider a post-pyloric feeding tube if a patient is at high risk of aspiration or is unable to tolerate gastric feeds^1,5

Promoting safe and effective enteral feeding requires careful attention to individualized feeding rates,⁶ patient positioning,^5-7and ongoing monitoring for complications.^1,6 By implementing evidence-based strategies, healthcare teams can optimize nutritional support while minimizing patient safety risks.

References

Heuschkel R, Duggan C. Enteral Feeding: Gastric Versus PostPyloric. UpToDate. https://www.uptodate.com/contents/enteral-feeding-gastricversus-post-pyloric. Updated February 5, 2025. Accessed February 2026.
Tappenden KA, Quatrara B, Parkhurst ML, et al. Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition. J Acad Nutr Diet. 2013;113(9):1219-37. doi:10.1016/j.jand.2013.05.015; PubMed PMID: 23871528
Cass AR, Charlton KE. Prevalence of Hospital-Acquired Malnutrition and Modifiable Determinants of Nutritional Deterioration During Inpatient Admissions: A Systematic Review of the Evidence. J Hum Nutr Diet. 2022;35(6):1043-58. doi:10.1111/jhn.13009; PubMed PMID: 35377487; PubMed Central PMCID: PMCPMC9790482
Barker LA, Gout BS, Crowe TC. Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. Int J Environ Res Public Health. 2011;8(2):514-27. doi:10.3390/ijerph8020514; PubMed PMID: 21556200; PubMed Central PMCID: PMCPMC3084475
Mizock BA. Risk of Aspiration in Patients on Enteral Nutrition: Frequency,Relevance, Relation to Pneumonia, Risk Factors, and Strategies for Risk Reduction. Curr Gastroenterol Rep. 2007;9:338-44. doi:10.1007/s11894-007-0039-7
Seres D, Patel J. Nutrition Support in Critically Ill Adult Patients: Enteral Nutrition. UpToDate. https://www.uptodate.com/contents/nutrition-support-in-criticallyill-adult-patients-enteral-nutrition. Updated June 10, 2025. Accessed February 2026.
Metheny NA. Preventing Respiratory Complications of Tube Feedings: EvidenceBased Practice. Am J Crit Care. 2006;15(4):360-9. doi:10.4037/ajcc2006.15.3.

Read, print & share

I AM PAtient Safety Achievement Awards

I AM Patient Safety 2026 Achievement Award Winners!

The Patient Safety Authority is pleased to announce the winners of the 2026 I AM Patient Safety Achievement Awards! Judges evaluated 169 nominations from 72 hospitals and facilities, and selected individuals and teams for their accomplishments in the following award categories:

Ambulatory Care
Commitment to Safety
Healthcare Disparity
Improving Diagnosis
Individual Impact
Medication Safety
Patient Communication
Safety Story
Transparency and Safety in Healthcare
Executive Director’s Award

Follow PSA on Facebook, Instagram, and LinkedIn, where we will post stories, photos, and videos celebrating these patient safety champions from May 4 through June 12.

Lessons From Event Reports

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), 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.

Just Published in Patient Safety

Wrong-Site Surgery: A Study of 664 Events From 237 Facilities Across a 10-Year Period

Wrong-site surgery (WSS) is defined as a “surgical or other invasive procedure performed on the wrong side, site, or patient, or an incorrect procedure performed on the patient.” This avoidable medical error continues to be significant problem in hospitals and ambulatory surgical facilities (ASFs).

Expanding on previous WSS research, the authors of this study took a novel approach: They reviewed and analyzed 644 WSS events reported in Pennsylvania from 2015 to 2024 and identified combinations of clinically related variables, such as type of facility, hospital procedure location, error type, clinician specialty, region of the body, and specific procedure. Among their findings: Most of these WSS events occurred in hospitals rather than ASFs, distributed across operating rooms, interventional radiology, and other procedural locations. The most frequently involved specialties were interventional radiology, pain management, and orthopedics.

This study represents one of the largest samples of WSS events examined in a single study. The authors have visualized their deep-dive analysis in 16 figures, tables, and supplemental appendices to help stakeholders comprehend the many combinations of variables contributing to WSS, identify these factors in their own facility, and design interventions to improve patient safety.

Submit a manuscript

Watch on YouTube

Chaos to Calm: Behavioral Management Strategies

In this previously recorded webinar, Belmont Behavioral Health System’s chief nursing officer Dawn Bausman, MSN, RN, and director of Training and Development Shawna Gigliotti, DrOT, OTR/L, described six fundamental tactics for reducing mechanical restraints and seclusion in hospitalized behavioral health patients. The implementation of this approach and associated interventions can serve as a roadmap for healthcare settings and programs trying to identify, prevent, and respond to patient aggressiveness in the least restrictive manner possible.