JHQ 310: Factors Associated With Nasogastric Tube Placement-Related Complications in a Single Academic Medical Center-JHQ 310: Article

JHQ 310: Article

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This article describes a quality improvement investigation at a 710-bed academic medical center after nine patients experienced injuries during nasogastric (NG) tube insertion attempts over 16 months (March 2021–July 2022), compared with no reported injuries in a similar prior period. An interdisciplinary taskforce reviewed the events and conducted a literature review showing NG tube complications are relatively common, with respiratory harm (including malposition and pneumothorax) frequently reported and potentially underrecognized.<br /><br />Case review found the facility’s cumulative complication rate was 0.43% (9 complications among 2,092 NG tube orders), comparable to or lower than published benchmarks. Most injuries were pneumothoraces (6 cases), with additional naso/oropharyngeal, esophageal, gastric, and distal perforations. Patients were all aged 72 or older and largely had neurologic (often stroke) or trauma diagnoses, most in intensive care. Complications occurred across varied tube types and were not associated with inserter education level or years of experience. Multiple insertion attempts were common, and concerns about supply-chain-related tube material changes were not supported by the manufacturer.<br /><br />Because root cause analyses did not reveal a single consistent technical or staff-related factor, the team focused on standardizing practice and escalation. Interventions included implementing a “difficult NG tube insertion” algorithm (modeled on difficult urinary and IV access pathways) that specifies best practices, contraindications, positioning, a defined limit on attempts, and when to escalate to more experienced clinicians or alternative methods. NG tubes with stylets were removed from general supply due to higher risk, and the hospital adopted a softer alternative tube after unit trials.<br /><br />After implementation and education (beginning March 2022; revised December 2022), the complication rate decreased to 0.25% (8 complications among 3,077 orders from Nov 2022–Feb 2024). The authors note limitations including reliance on voluntary event reporting and small sample size, and they recommend broader awareness and reporting of NG tube placement risks.

Keywords

nasogastric tube insertion

quality improvement investigation

pneumothorax complication

tube malposition respiratory harm

difficult NG tube algorithm

ICU elderly patients

multiple insertion attempts

stylet NG tube risk

standardized escalation pathway

complication rate reduction