Medication Errors

Watch where those tubes end up

These docs pushed too hard, with dire results

In April a $1.1 million lawsuit was brought - and won - against a surgeon for misplacement of a feeding tube in a woman with cancer. The physician was supervising a resident, and the tube became lodged in the wall of the small intestine instead of the stomach, causing infection and further surgery. The manufacturer of the feeding device recommends injecting contrast dye after the tube is inserted, followed by an X-ray to ensure proper placement. That procedure allegedly was not followed.

In a similar incident last year, when London physicians attempted to insert a nasogastric tube into a patient with epilepsy, fatal complications ensued. The middle-aged woman was admitted following a prolonged seizure and treated with diazepam, but she remained comatose. To reduce aspiration risk, three attempts were made at insertion, but each produced blood-stained fluid. Finally, physicians ascertained that the fluid must be nasal secretion and left the tube in place. In fact, a coiled length of tube had passed through the base of the patient's skull, and she ultimately died of overwhelming sepsis from bronchopneumonia and meningitis. A postmortem revealed a defect in the roof of the patient's nasal cavity. The lesson here, according to case report authors, is never to substitute nasogastric tubes for cuffed endotracheal tubes, especially if the patient has a history of head trauma or epilepsy that may suggest the possibility of a cranial defect.