Misplaced Feeding Tubes – A “Never Event” in Medical Treatment

“Never Events” are adverse medical incidents which are by definition caused by medical negligence.

Included among these are misplaced feeding tubes. It is important for patients and their families to understand that when they are seriously injured by one of these never events, they likely have a medical malpractice claim against the medical provider(s).

There are many challenges to medical malpractice claims. There are also unique and critical deadlines on medical malpractice claims.

As such, if you or a loved one has suffered serious personal injury or wrongful death as a result of one these events, it is important to contact a medical malpractice attorney right away.

Many different patient advocacy groups have sprung up in recent years to address the persistent problem of never events. For example, the American Association of Critical-Care Nurses (AACN) compiled a list of guidelines based on a wide-range of available evidence to help guide medical care professionals in eliminating these errors. Quite simply, these guidelines, known as “Practice Alerts,” represent steps that should be followed 100% of the time in order to keep patients safe.

Consider one of the most common types of never events: misplaced feeding tubes. Many patients need to receive nutrients into their stomach via these tubes. For instance, some patients such as those with cancer or anyone having problems affecting the throat or mouth might requiring a feeding tube. When not inserted correctly, these tubes can cause serious problems.

When nurses are negligent in inserting the tube it may feed nutrients directly into the bloodstream. At other times the tube incorrectly may send material to the lungs, potentially leading to pneumonia. Tubes can also perforate the gastric system or even dislodge, causing leakage that leads to asphyxiation.

The problems arise much more frequently than is acceptable considering the rather routine nature of these procedures. One study reviewed more than 2,000 feeding tube insertions and found misplacements in 1.3 to 3.2 % of the insertions, and 28% of those misplacement resulted in pneumonia or pneumothorax.

Feeding tube errors can be prevented with adherence to proper safety protocols outlined by the AACN. The ACCN has issued a Practice Alert for verification of feeding tube placement. The Practice Alert prescribes a variety of bedside methods to be followed, such as observing for signs of respiratory distress. It also requires obtaining an x-ray to confirm that the tube was correctly placed before it is used. The guidelines calls for checking tube location every 4 hours after feedings begin.

Additionally, the Practice Alerts provide for staff training so that nurses and other professional staff follow the practices identified in the alerts consistently. The evidence shows that inter-professional teams, including nurses, doctors, and other professionals, are most effective in implementing the alerts. Hospitals and their administrators need to understand the importance of this training to keep patients safe.

Again, if you or a loved one has been negatively affected by a hospital-acquired health care problem, such as a misplaced feeding tube, you should contact an attorney right away for a review of your case. When a never event occurs, almost by definition, medical negligence will be to blame.


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Collins & Collins, P.C.
Albuquerque Attorneys

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