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

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.

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.

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

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.