RT Journal Article SR Electronic T1 Patient safety matters: reducing the risks of nasogastric tubes JF Clinical Medicine JO Clin Med FD Royal College of Physicians SP 228 OP 230 DO 10.7861/clinmedicine.10-3-228 VO 10 IS 3 A1 Iain E Yardley A1 Liam J Donaldson YR 2010 UL http://www.rcpjournals.org/content/10/3/228.abstract AB Nasogastric tube insertion is a common clinical procedure carried out by doctors and nurses in NHS hospitals daily. For the last 30 years, there have been reports in the medical literature of deaths and other harm resulting from misplaced nasogastric tubes, most commonly associated with feed entering the pulmonary system. In 2005 the National Patient Safety Agency in England assembled reports of 11 deaths and one incident of serious harm from wrong insertion of nasogastric tubes over a two-year period. The agency issued a safety alert setting out evidence-based practice for checking tube placement. In the two and a half years following this alert the problem persisted with a further five deaths and six instances of serious harm due to nasogastric tube misplacement. This is a potentially preventable error but safety alerts advocating best practice do not appear to reliably reduce risk. Alternative solutions, such as standardising procedures, may be more effective.