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Learning from errors
False-positive pH aspirates after nasogastric tube insertion in head and neck tumour
  1. Claudia Kate Sellers
  1. Guys and St Thomas’ Hospital, London, UK
  1. Correspondence to Dr Claudia Kate Sellers, claudiesellers{at}hotmail.co.uk

Nasogastric (NG) feeding tubes are commonly inserted to supplement enteral nutrition in certain patient groups, including those with head and neck cancers where swallowing may be compromised. An NHS National Patient Safety Alert was released in 2011 detailing ongoing cases of significant morbidity and mortality attached to the incorrect placement of NG feeding tubes in hospital inpatients. Since 2005, there were 21 deaths and 79 cases of harm nationally due to feeding into the lung through misplaced tubes. pH testing remains the first-line method of placement confirmation, with chest x-ray used when no aspirate is gained or where pH testing fails to confirm suitable acidity. We present a case report describing false-positive NG tube placement confirmation tests in a patient with head and neck cancer, who was administered feed into lung parenchyma with significant morbidity. We discuss the case for specific NG tube placement protocols in head and neck cancer patients.

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