Rare false positive test and X-ray error landed Hong Kong tube-fed man in intensive care
- Expert panel rules test suggested feeding tube was in stomach and chest X-ray check did not cover abdomen area so problem undetected
A feeding tube ended up in a Hong Kong patient’s airway rather than his stomach because of a freak test result and a junior doctor’s inexperience in reading X-rays, an expert panel said on Friday.
Dr Tang Kam-shing, the chairman of the six-strong panel, said the incident happened because of a “chain of unfortunate events” that left a 61-year-old man in critical condition in intensive care after the mistake was not noticed for two days.
The panel explained that the feeding tube was inserted and a standard test used internationally as well as in the city was used to check acidity – the pH level – to make sure the tube had gone into the stomach, but that it had returned a rare false positive.
Tang said the stomach was usually acidic and the test had returned a pH level below 5.5, which meant the tube was in an acidic environment.
“The root cause analysis committee thinks this is an uncommon case of false positive result, coming from such a chain of unfortunate events,” he added.
“The nasogastric tube has gone via the left bronchus into the left pleural space, which is the space between the lung and the thoracic cage.”
