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Based on record reviews and interview, the medical staff failed to follow the Bylaws for supervision , and policy for the verification of the of the feeding tube (Dobhoff tube) placement by qualified staff in 1 out of 12 sample patients (SP) #1.


Findings include:


Record review of (Sampled Patient) SP #1 x-ray of the abdomen report dated 4/8/2017 at 6:46 PM. showed in the findings: there is a weighted feeding tube identified, taking an odd course, the tip projecting over the right-sided (lumber) L1 vertebral body.

Record review of SP #1 Nurse's Progress Notes dated 4/8/2017 at 7:00 PM showed that at 19:00 (7:00 PM) (the nurse) received the patient awake, alert on 2 liters nasal cannula, sats (oxygen saturation) at 100%, with tube feeding of Jevity running at 20 ml (milliliters)/ hr(hour) via micro-feeding tube. At 23:00 (11:00PM) the patient complained of shortness of breath and asked for respiratory treatment. Called [Named] Physician and informed him that patient is short of breath. Called the respiratory therapist and treatment was given. The [Named] Physician and the CRNA (Certified Registered Nurse Anesthetist) came and assessed the patient. The Charge Nurse also informed and at bedside. ABG (Blood Gas) was done. The physician decided to intubate the patient. The Patient was intubated at 23:30 (11:30 PM) with an ETT (breathing tube). Head bed maintained at 30 degrees. Vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation) stable.

Record review of SP #1 Anesthesiology Consultation notes, had an Addendum by the Anesthesiologist that showed the feeding tube noted to be in the trachea and was immediately removed. This Addendum was added to the Anesthesia Consultation Final Report electronically signed by the physician on 4/8/2017 at 11:48 PM.

The Discharge Summary, dictated 06/02/2017, and signed on 06/03/2017, showed following admission he developed acute renal insufficiency likely due to contrast nephropathy, acute hypoxic respiratory failure from aspiration pneumonia (failed swallow on 4/8/17) requiring emergent intubation on 04/8/17, septic shock from aspiration pneumonia (MRSA (Methicillin-resistant Staphylococcus aureus), enterobacter, and coronavirus)leading to worsening of his acute renal insufficiency ultimately tracheostomy (5/2/17), left sided pneumothorax.

Interview with the Medical Director /Trauma Team on 6/28/2017 at 11:05 AM revealed that the feeding tube was placed into the right side of the lung. The issue was the reading of the x-ray. The Fellow who inserted the micro-feeding tube read the x-ray. The x-ray showed a "non-classic" finding of malposition of the tube.

The Associate Director of Quality/ Compliance Office, and the Risk Manager stated on 6/28/2017 at 11:45 AM revealed that
Nurses do not insert micro-feeding tube. Only Doctors can insert this tube and, placement check after insertion is determined by an x-ray.

The policy "Feeding (Enteral) Tubes" (dated 07/21/2014) state to re-evaluate the feeding tube position radiographically if any doubt arises regarding placement. The policy also states, for verification of the tube placement: An x-ray is interpreted by a resident (at least a PGY2), or attending involved in the patient's care, a radiologist (attending or resident in at least their first year of radiology training), or an APN/ PA credentialed to read x-rays.

The fellow who inserted the feeding tube on SP #1 was a PY-1; being trained in the Department of Anesthesiology and according to the letter of acceptance began training on 03/1/2017.

The " Bylaws and Rules and Regulations of The Medical Staff " dated December 21, 2016, states in section 4.2 The Active Academic and Active Community Medical Staff shall demonstrate clear evidence of a commitment to assume all the functions and responsibilities of membership on the Active Medical Staff, including, where appropriate, supervision of resident/fellows.


Record review from the Trauma ARNP (Advanced Registered Nurse Practitioner) sent on June 6, 2017 at 11:52 AM addressing the M & M (Morbidity & Mortality) for this case to be presented. Record review of Trauma M & M Presentation revealed updated 6/29/2017 and this case is included. Record reviews of title ACADEMIC CONFERENCE TRAUMA ATTENDANCE RECORD dated 4/13/2017, 4/20/2017, 5/4/2017, 5/11/2017, 5/18/2017, and 6/1/2017 do not have attendance of the Anesthesia Fellows and no indication this case was discussed to the entire team.

In order to mitigate future incidents, the following action plan items were planned (dated 7/3/2017): Update the process for the insertion and verification of a feeding tube- target. Estimated date of completion September 2017. Education of ICU (Intensive Care Unit) Nurse Practitioners (NP), Physician (PA), Assistant, Residents and Fellows with the updated process. Estimated date of completion September 2017. Created formalized/ structured departmental orientation program for this facility's ICU Fellows, Residents, NPs and PAs. Estimate date of completion October 2017. These three action plans are under the ICU Anesthesia Leadership responsibilities. These action plans were not started and presented at the time of survey dates.