Factors Associated With Nasogastric Tube Placement-Related Complications in a Single Academic Medical Center.

Objective: At our 710-bed academic medical center, nine (9) patients sustained injuries during nasogastric (NG) tube insertion attempts over a 16-month period (March 2021-July 2022). No injuries were reported during the comparable period before these events. This increase in reported events prompted an in-depth analysis to determine the root causes and implement a process improvement plan.

Methods: Root cause analysis (RCA) of these events failed to identify risk factors or actionable themes. The RCAs demonstrated wide variation in the number of insertion attempts and techniques.

Results: A standard process was created to provide team members with guidance for escalation when NG tube placement was difficult.

Conclusions: Although the complication rate for NG tube insertion was comparable with the criterion standard for large tertiary care institutions, we focused on minimizing risk and improving outcomes by creating a standard process for NG tube placement.