A nasogastric or NG tube is a plastic tubing device that allows delivery of nutrition directly into the stomach (feeding), or removal of stomach contents (drainage). It is passed via the nose into the oropharynx and upper gastrointestinal tract. Many times these tubes can be malpositioned, leading to significant harm and even death. The National Health Service Improvement (NHSI) in the United Kingdom has placed this type of incident on their “never events” list; never events are “errors in medical care that are identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.” (National Quality Forum)

Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.

Actionable steps include:

• Executive Summary Checklist
• Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
• Performance improvement plan to follow if improvements are necessary
• Clinical workflow for preoccupation with workflow for areas of improvement
• How to educate patients and family members about the significance of their role throughout the continuum
• Guidance on how to measure outcomes