Beyond the “Never Event”: A Qualitative Content Analysis of Ongoing Nasogastric Tube Position Testing Incidents

Objective: Clinicians are encouraged to report all health care incidents, but only those causing serious harm are routinely reviewed to improve patient care. There is no consensus on the best method of confirming ongoing nasogastric tube (NGT) position, leading to variation in practice. The aim of this study is to evaluate the clinical contexts of incidents related to ongoing NGT position testing and assess the efficacy of current clinical practices. Method: Incident databases in Queensland Health, Australia and NHS England were searched by data custodians for incidents mentioning NGTs. A multidisciplinary team compared the extracted incidents to the inclusion and exclusion criteria. Qualitative content analysis (where incidents were coded into themes) was used to evaluate the incidents. Results: Five of 27 Queensland incidents, 24 of 412 English incidents, and 2 of 26 English Never Events met the inclusion criteria. No incidents in Queensland resulted in harm. The 2 Never Events resulted from a displaced NGT being used. Three of the 24 incidents in England resulted in low-level harm, but were not related to NGT displacement. The themes identified: (1) outcomes related to ongoing NGT position testing, such as missing medications due to inconclusive pH testing, (2) staff interpersonal relationships impacting their ability to follow local procedures, (3) nonadherence to local procedures, and (4) poor quality of incident reports. Conclusions: Qualitative content analysis successfully identified themes relevant to clinical practice, despite the low quality of individual incident reports. Harm from displaced NGTs was rare but delays from procedural inconsistencies warrant review of current practices, particularly the reliance on pH testing.