Nasogastric Tube Placement: The Confirmation Step That Prevents a Never Event

Passing a nasogastric tube is a simple procedure with one catastrophic failure mode: the tube goes into the lung, someone feeds through it, and the patient dies or is seriously harmed. This is classified as a never event in many health systems, and the failure is almost never the insertion — it is the confirmation.

At a glance

Before you start

Check the indication and whether there is any reason not to proceed. Base of skull fracture, significant facial trauma, recent upper gastrointestinal surgery, oesophageal varices or stricture, and coagulopathy all change the picture, and some of them mean this is not your procedure to perform.

Explain what will happen and agree a signal the patient can use to ask you to pause — raising a hand works, since they will not be able to speak comfortably.

How it is done

1. Sit the patient upright unless contraindicated.
2. Examine both nostrils and choose the more patent side.
3. Measure the length to be inserted using the method your policy specifies, and note the marking so you know how far it has gone.
4. Lubricate the tube.
5. Pass it along the floor of the nose, directed backwards rather than upwards.
6. When it reaches the pharynx, ask the patient to swallow — offer sips of water only if it is safe for them to swallow — and advance with each swallow.
7. Stop immediately if the patient coughs persistently, chokes, becomes distressed, or their voice changes. Withdraw.
8. Advance to the measured marking.
9. Secure the tube and record the external length at the nostril.
10. Confirm position by an approved method before anything is instilled.
11. Document insertion, external length, confirmation method and result, and who confirmed it.

Confirmation, and why one method is banned

The traditional test of injecting air and listening over the stomach is unreliable. Sounds transmit, and a tube in the lung can produce a convincing noise over the epigastrium. It has been implicated in deaths and it must not be used as a confirmation method.

Approved confirmation uses aspirate testing against a defined pH criterion, and radiographic confirmation where aspirate cannot be obtained or is inconclusive. The specific criterion, the sequence, and who is permitted to interpret a confirmatory film are all set by your hospital’s policy — and that policy is what you follow, every time, without local improvisation.

The rule that matters most: nothing goes down the tube until position is confirmed. Not feed, not medication, and not water. Water is the one people rationalise, and water in the lung is aspiration.

It can move afterwards

A correctly placed tube can migrate with coughing, vomiting, retching or patient movement. That is why position is rechecked at the intervals your policy defines — typically before each feed or medication, after vomiting or coughing episodes, and if the external length has changed. Recording the external length at insertion is what makes that check possible.

What can go wrong

What seniors actually ask

• How did you confirm position?
• What was the external length, and is it the same now?
• Has anything been put down it yet?
• Who interpreted the confirmatory imaging?

Last-minute checklist

• Contraindications checked before starting
• Withdraw on coughing, choking or voice change
• Advance only to the measured marking
• External length recorded
• Position confirmed by an approved method — never by auscultation
• Nothing instilled before confirmation, including water
• Rechecked at the points your policy specifies

References

• Your hospital’s nasogastric tube placement and confirmation policy
• National patient safety guidance on nasogastric tube misplacement