Since I work as a pediatric nurse, I chose a malpractice case related to infant injury due to the failure to manage medical equipment properly. This case involves a premature infant who suffered severe brain damage following a preventable cardiac arrest caused by improper nasogastric (NG) tube management, ultimately leading to ventilator dependence and lifelong disabilities.

Case Summary
On January 18, 2024, a medical malpractice lawsuit was filed against Greater Baltimore Medical Center (GBMC) regarding caring for an infant born at 25 weeks gestation (Wais, Vogelstein, Forman, Koch & Norman, LLC, 2024). Despite initial stability, the infant required prolonged respiratory support due to chronic lung disease and gastroesophageal reflux disease (GERD). The child frequently dislodged his NG tube, a risk known to healthcare providers (Wais, Vogelstein, Forman, Koch & Norman, LLC, 2024). On July 26, 2022, the infant experienced a critical event where the NG tube was found dislodged, and he was vomiting. The response to his deteriorating condition was delayed, and no code sheet was created during the resuscitation (Wais, Vogelstein, Forman, Koch & Norman, LLC, 2024). As a result, he suffered a 32-minute cardiac arrest, leading to severe hypoxic-ischemic brain injury. Despite extensive interventions, the infant now requires lifelong ventilator and tracheostomy support and has significant neurological impairments (Wais, Vogelstein, Forman, Koch & Norman, LLC, 2024).

What Went Wrong?
Several failures in patient care contributed to this adverse event, but I think that these are the ones that were the most preventable:

Lack of Proper Documentation—There is no record of NG tube placement verification before feedings, which should have been completed (Wais, Vogelstein, Forman, Koch & Norman, LLC, 2024). Also, nursing judgment for checking an NG or GT tube placement is no longer considered safe practice (Richardson et al., 2006). Nursing should verify the placement with PH paper, not auscultation, since it is safer and the only sure way (without X-ray) to confirm placement (Richardson et al., 2006).

Failure to Monitor & Respond Promptly – The infant’s history of pulling out his NG tube was known, yet proactive measures were not taken. While there was an attempt to place a GT with fundoplication on July 19, which was canceled due to respiratory destabilization and the surgeon’s request to change hospitals for more medical support with surgery, on July 26, the child still had the NG tube in place (Wais, Vogelstein, Forman, Koch & Norman, LLC, 2024). The medical team should have made arrangements to have a GT placed as soon as possible and arranged to have OR time booked.

Inadequate Emergency Response—No code sheet was created, and critical interventions (e.g., intubation and epinephrine administration) were delayed (Wais, Vogelstein, Forman, Koch & Norman, LLC, 2024). Without a code sheet, there is not an adequate log of the code, which would have caused confusion when trying to review the code to determine the times of interventions.

Workplace Safety, Risk Management, and Quality Improvement

To prevent similar occurrences, healthcare facilities must implement the following improvements:

Strict NG Tube Management Protocols: To prevent false placement errors, placement verification must be documented before each feeding with gastric pH paper (Richardson et al., 2006).

Standardized Code Blue Documentation: Ensuring accurate and timely record-keeping during resuscitation efforts. Code teams should have specific roles and know them at the beginning of the shift to prevent confusion.

Staff Training & Simulation Drills: Regular education on airway management and emergency response in neonatal patients. Mock codes to simulate with staff codes and prepare for emergencies.

Preventative Measures for Future Risk Management

If I were responsible for preventing such incidents, I would implement the following into the risk management plan:

Mandatory Double Verification—Nurses must confirm NG tube placement before feedings with pH paper. If placement cannot be confirmed via pH paper, then an X-ray should be consulted.

Alerts for High-Risk Patients—Implement a tracking system for infants prone to dislodging tubes. This would include having the patient not be alone in the room or having family present to alert staff of NG tube dislodgement immediately. Chart NG placement during care, check placement of the NG at regular intervals on the shift, and prioritize having gastric tubes placed to avoid long-term NG tubes for feeding.

Resuscitation Protocol Reinforcement – Ensure all staff adhere to standardized emergency response documentation.

Thank you,

Rachael

References:

Richardson, D. S., Branowicki, P. A., Zeidman-Rogers, L., Mahoney, J., & MacPhee, M. (2006). An Evidence-Based Approach to Nasogastric Tube Management: Special Considerations. Journal of Pediatric Nursing, 21(5), 388–393. https://doi-org.lopes.idm.oclc.org/10.1016/j.pedn.2005.09.001

Wais, Vogelstein, Forman, Koch & Norman, LLC. (2024). Wais, Vogelstein, Forman, Koch & Norman, LLC. https://www.malpracticeteam.com/infant-injury-due-to-failure-to-properly-manage-medical-equipment-january-18-2024