Abstract. The placement of nasogastric (NG) tubes is known to be prone to error and may lead to serious issues for patient
safety and wellbeing. In some instances these have been catastrophic and resulted in the death of the patient. This study sought
to explore the potential risks associated with this procedure through the use of systematic prospective risk assessment. The
research team used the Prospective Hazard Analysis (PHA) toolkit developed by Ward et al (2010) . The study has shown a
wide number of risks that cover equipment design, work organisation, and training issues. The link between equipment design
and training provides an important example of the need for a systematic approach to reducing errors and improving resilience
in this aspect of healthcare.