Nutrition in Clinical Practice Volume XX Number X Month 201X 1 –3 © 2014 American Society for Parenteral and Enteral

hosted at online.sagepub.com Invited Commentary In 1999, the Institute of Medicine (IOM) estimated as many as 98,000 people die each year from healthcare-related errors.1 Although a great deal of work has occurred in the past 15 years to improve safety, patients continue to experience harm as a result of clinical care and treatment. Our ultimate goal must be to eliminate harm events related to healthcare delivery, but to do so, we must understand the errors that occur and how to design systems and processes that prevent such errors. With all this emphasis on safety, it begs the question: why are nasogastric (NG) tubes still ending up in the lungs of infants and children? NG tubes are commonplace in pediatric practice, yet sig-nificant harm events have occurred related to misplaced NG tubes. Understanding the epidemiology of NG tube misplace-ment is challenging. National reporting of NG tube harm events is not standardized, and methods to verify tube place-ment vary across organizations. To learn from and eliminate harm related to NG tube misplacement, further study is needed as well as a clear framework to base interventions. An interdis-ciplinary group sponsored by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), titled New Opportunities for Verification of Enteral tube Location (NOVEL), has formed with a mission to identify and promote best practices for accurate NG tube placement for inpatient and outpatient pediatric patients. In addition, the NOVEL group is interested in the potential of technology development that will support reliable and accurate determination of NG tube place-ment. In this issue of Nutrition in Clinical Practice is an article by Irving et al2 entitled “The Challenge of Nasogastric Tube Placement and Verification in Pediatric Patients: Review of the Current Literature. ” The reader is encouraged to read more about this clinical dilemma. Regardless of the challenges, NG tube misplacement has a significant impact on patients, families, and clinical staff, and it is imperative that we develop strategies to eliminate harm associated with the use of NG tubes. This impact is evident in the following 2 individual and unrelated events as described by a parent and a nurse