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Learning from errors
Beware of the malformed nasogastric tube
  1. Rakesh Garg,
  2. Puneet Khanna,
  3. Siva Kumaran S,
  4. Abraham Sonny
  1. Department of Anaesthesiolgy and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 10029, India
  1. Rakesh Garg, drrgarg{at}


Untoward events with faulty instruments and apparatus are well known and if not recognised can be disastrous. We present a case of a faulty nasogastric tube having both ends sharp-edged and closed with a detachable blocker. In our case, had we inserted the faulty nasogastric tube, the impact of the blocker, although small, in the tract could have eroded the nasal/oesophageal/gastric mucosa causing its sequalae. Thus, we would like to emphasise the need to check all instruments before using them to prevent any catastrophic complication.

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  • Competing interests: none.

  • Patient consent: Patient/guardian consent was obtained for publication.

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