Patient Condition

• A 45-year-old female patient was inserted with a 14Fr Levin tube in the intensive care unit. As the patient was thin, the physician selected a 14Fr tube rather than a 16Fr tube.
• To check that the Levin tube was located inside the stomach, the physician put air in using a syringe and subsequently observed with a stethoscope.
• To double-check that the Levin tube was properly placed in the patient's stomach, a chest X-ray was taken.

Events

• The radiologist failed to find the Levin tube from the patient's chest X-ray image. Refer to Figure (a).
• Normally, the Levine tube would be observed in the chest X-ray image as shown in Figure (b).

Post-event management & Health effect

• Removed the Levin tube for patient safety and inserted another 14Fr tube.
• The patient retook a chest X-ray to check for the right placement of the Levin tube.
• The patient expressed discomfort in the nose area due to repeated insertion.

Investigations (Cause, Improvements)

• Quality manager of the manufacturer detected that the radio-opaque line impregnated was narrower in width and contained smaller amount of barium sulfate at the tip, compared to the Levin tube of the same lot.
• The manufacturer decided to increase the width of the radio-opaque line to 8 mm for the Levin tube.

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