Misplacement of nasogastric tubes can have disastrous consequences for patients and is listed as a "never event" by NHS England. When Lancashire Teaching Hospitals NHS Foundation Trust had two of these never events, the nutrition nursing team carried out a system-wide evaluation to identify problems and develop plans to address them. An e-learning package, robust standardisation in staff's approach to patient care, re-setting "red lines" to support and empower staff, and the introduction of monitoring and reporting systems have contributed to improving patient safety.
Earley, T. 2019. Improving safety with nasogastric tubes; a whole-system approach. Nursing Times; 115: 12, p 50-51