Patient Safety


This section contains safety alerts from the NHS and details of relevant coroner's regulation 28 reports.
The society welcomes contributions to this page from members and if there is an issue you believe should
 be highlighted to the wider profession please contact
For details of patient safety alerts and shared learning please click on the links below.

Manual bolus dose of insulin
(Adobe PDF File)
Vascath stylet fault
(Adobe PDF File)

Harm from misplaced nasogastric tube

Patients are continuing to be harmed from misplaced nasogastric (NG) tubes due to misinterpretation of chest x-rays (CXRs). This is despite a number of national safety alerts over the last decade and its inclusion as a never event. The learning from a recent incident has been shared by the ICU involved, and is available to read here.

Units must ensure that all staff who interpret CXRs for NG tube placement have completed competency based training and use the recommended four-point criteria.

An online training package is also available at eLearning for Health (
SBAR NGT Never Event
(Adobe PDF File)