Mode of failure to identify tube misplacement
| Type of failure | No. of cases |
| pH test correctly carried out but invalid (pH<5.5 but tube not in stomach) | 10 |
| pH test wrongly interpreted (thought OK if pH=6) | 1 |
| Aspiration used as checking procedure; unclear whether pH tested | 5 |
| Bubble or Whoosh test used as only checking procedure | 2 |
| CXR incorrectly interpreted | 25 |
| Correct test indicated tube in stomach but tube moved prior to starting feed | 4 |
| No action taken to assess tube placement | 12 |
| CXR done but not checked prior to feeding | 2 |
| Other (misinterpretation of CXR report) (CT scan misreported)(direct vision and no further checks) | 3 |
| Total | 64 |