In the NHS, some incidents are classed as “Never Events” — patient safety incidents considered so preventable that, with the right checks in place, they should never happen.

Feeding through a misplaced nasogastric tube is one of them.

NHS England’s provisional data recorded 28 incidents of “misplaced naso/oro gastric tubes and feed administered” in just a 10-month window (April 2020–January 2021) — despite national safety alerts going back to the 2016 alert, “Nasogastric tube misplacement: continuing risk of death and severe harm.” And the incident rate remains approximately the same today.

But this isn’t only a UK story. In the United States, a major study of blind feeding-tube placement found airway misplacement in 3.2% of patients — a figure its authors called “alarming.” Across Europe, the same risk drives the same caution. Different health systems, the same challenge.

If you place or check NG tubes — in London, Madrid or Boston — you already know how much care it takes. The question worth asking everywhere is whether the tools and checks we hand clinicians give them the best possible chance of getting it right, first time.

Sources: NHS England Provisional Never Events publication (Apr 2020–Jan 2021); NHS Patient Safety Alert (2016); de Aguilar-Nascimento & Kudsk, JPEN, 2007.