Completed Did Not Mean Read: A Root Cause Analysis of Tube Feeding Started Through a Feeding Tube Lying in the Right Lower Lobe Bronchus
Student Name
American College of Education
NUR5053: Quality Improvement and Safety
Module 2 Assignment
Instructor Name
October 20, 2026
The Event
The patient was a 71-year-old woman admitted to the neuroscience step-down unit two days after a left middle cerebral artery stroke. She failed her bedside swallow screen and a follow-up evaluation, and the team ordered a small-bore feeding tube and continuous enteral nutrition. The patient, her course and the unit are composites described for this assignment, built from the pattern of events reported in the literature.
At 2150 the night nurse placed the tube at the bedside using the unit's blind technique, measured and recorded the external length at the nostril, and ordered a portable radiograph to confirm placement. The image was taken at 2320. At 0105, while checking her patients' orders, the nurse saw the imaging order marked Completed in the electronic health record, took that as confirmation, and started the feeding pump at 20 mL per hour. The radiograph had in fact been acquired but not read; overnight, routine portable films at this hospital went to a teleradiology queue with a typical turnaround of three to four hours. At 0450 the patient began coughing, and her oxygen saturation fell to 86% on room air. The rapid response nurse stopped the feeding at 0500. The radiologist's report, issued at 0535, described the tube tip in the right lower lobe bronchus. The tube was removed, the patient was transferred to intensive care with aspiration pneumonia, and she returned to the step-down unit four days later.
This was a serious safety event, reported by the charge nurse the same morning and reviewed by a team that included the unit manager, a staff nurse from another unit, a radiologist, a clinical informatics nurse, a dietitian and the patient safety officer.
Method
The review followed the RCA2 guidance published by the National Patient Safety Foundation (2015), which was written because many root cause analyses stopped at the person nearest the event and produced weak actions. RCA2 asks the team to build a timeline, look for causes in several categories, write causal statements that link a cause to the outcome through a chain of effect, and choose actions using a hierarchy that rates them by how much they depend on human memory. The review team interviewed the night nurse, the charge nurse, the rapid response nurse and the radiologist on duty, examined the audit trail in the electronic record and observed two tube placements on the unit in the following week. Reason (2000) described adverse events as the moment when holes in several layers of defense line up; the task of the review was to find each layer and the hole in it.
Causes
The first hole was in the verification step itself. The unit's feeding tube policy said feeding could begin after placement was confirmed, but it did not say who confirmed it or how that confirmation would reach the nurse. Nothing in the enteral nutrition order set required a documented radiograph result before the order became active. Verification depended entirely on the nurse remembering to look for a read report.
The second hole was in the electronic record. The imaging order status changed to Completed when the technologist finished the exam, not when the radiologist reported it. In interviews, four of six nurses on the unit said they understood Completed to mean the result was available. The night nurse had followed what she believed the screen told her.
The third hole was in timing. Feeding tube radiographs were ordered at routine priority. At night, routine films waited in a queue behind emergency studies, and the hospital had no category for a film whose only purpose was to release a treatment waiting at the bedside. Nurses who wanted a faster read had to call the radiologist, and several said they did not like to do so for a feeding tube.
The fourth hole was in the placement technique. The patient had right-sided weakness and reduced alertness, both of which weaken the cough reflex that might otherwise warn a nurse of airway placement. Metheny et al. (2019) reviewed 14 national guidelines and found that all agreed radiography is the most accurate method of confirming placement, while bedside methods such as auscultation were the least favored. Koopmann et al. (2011) found that in high-risk patients, blind bedside placement led to airway placement in 20 of 1,822 insertions, and that a dedicated team using electromagnetic tracking eliminated airway placement in 1,154 insertions. The unit used a blind technique for every patient regardless of risk. No single nurse caused this event; four defenses each had a gap, and on this night the gaps lined up.
Causal Statements
RCA2 asks for causal statements that name a cause, its effect and the event, so that each can be tested and acted on. The review produced four. Because the electronic record displays an imaging order as Completed when images are acquired rather than read, nurses can believe placement has been confirmed when it has not, which increased the likelihood that feeding began through a misplaced tube. Because the enteral nutrition order can be started without a documented placement result, verification depends on individual memory, which allowed feeding to begin without confirmation. Because feeding tube radiographs have no priority category and are read in a routine overnight queue, confirmation can take several hours, which increases the pressure to start feeding before a result is available. Because the unit uses blind bedside placement for all patients, including those with reduced alertness and a weak cough, airway placement is more likely and less likely to be detected at the bedside, which increased the likelihood of the initial misplacement.
Actions, Ranked by Strength
The action hierarchy in the RCA2 guidance sorts actions into stronger ones, which change the system so that the error becomes hard to make, intermediate ones, which make it less likely, and weaker ones, which still depend on staff recalling a rule at the right moment (National Patient Safety Foundation, 2015). The review chose two stronger actions, two intermediate actions and one weaker action, and gave each an owner and a measure.
The first stronger action is a forcing function. The informatics team will change the enteral nutrition order so that the pump administration cannot be documented, and the order cannot be released to the feeding pump workflow, until a radiologist's result confirming gastric or post-pyloric placement is filed. Owner: the director of clinical informatics, within 60 days. Measure: monthly audit of feeding starts, with a target of no feeding started before a filed placement result. The second stronger action is standardization of technique for high-risk patients. Patients with reduced alertness, an absent cough or an artificial airway will have tubes placed by trained nurses using electromagnetic guidance, following the model Koopmann et al. (2011) described. Owner: the nursing director, within six months, beginning with a business case. Measure: the percentage of high-risk placements performed with guidance.
The intermediate actions are to relabel the imaging status so that acquired and read are shown separately, and to create a priority category for tube placement films with a target read time of 60 minutes at night. The weaker action is education: a one-page review of why auscultation and the Completed label are not confirmation. It is included because staff asked for it, but on its own it would not have prevented this event. Boullata et al. (2017), in the safe practice recommendations of the American Society for Parenteral and Enteral Nutrition, describe the same principle: safety in enteral nutrition depends on standardized processes at every step, not on the vigilance of whoever is on duty. If the hospital does only the education, it has written a better memo and left every hole in place.
References
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii-Wolfe, C., Sullivan, J., Wood, A., Malone, A., Guenter, P., & ASPEN Safe Practices for Enteral Nutrition Therapy Task Force. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. https://doi.org/10.1177/0148607116673053
Koopmann, M. C., Kudsk, K. A., Szotkowski, M. J., & Rees, S. M. (2011). A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Annals of Surgery, 253(2), 297-302. https://doi.org/10.1097/SLA.0b013e318208f550
Metheny, N. A., Krieger, M. M., Healey, F., & Meert, K. L. (2019). A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes. Heart & Lung, 48(3), 226-235. https://doi.org/10.1016/j.hrtlng.2019.01.003
National Patient Safety Foundation. (2015). RCA2: Improving root cause analyses and actions to prevent harm.
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
How this NUR 5053 Module 2 example is structured
NUR 5053 Module 2 often asks for a root cause analysis of a composite adverse event, ending in ranked actions; your classroom's instructions decide the template and whether a fishbone or timeline must be attached. This example follows the RCA2 approach: a factual timeline, a search for system causes in several categories, causal statements written in the required form, actions sorted by the action hierarchy from stronger to weaker, and a measure for each action so the organization can tell whether it worked.
NUR5053 Module 2 questions, answered
What does NUR5053 Module 2 usually ask for?
NUR5053 Module 2 often asks for a root cause analysis of a composite or de-identified adverse event: a timeline, the contributing causes, causal statements and actions to prevent it happening again, sometimes with a fishbone diagram. Your classroom's instructions decide the template.
Why not include the nurse's error as a root cause?
Because the analysis asks why a competent person could make that error, and the answer is always in the system around her. Human actions appear in the timeline, but causal statements describe the conditions that made the action likely, which is where prevention is possible.
How many actions should an RCA include?
Enough to address each causal statement, usually three to six, with at least one stronger action from the hierarchy. Each needs an owner, a date and a measure. A plan made only of education and policy reminders will be marked down.
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