misinsertion

Misinsertion is the act of inserting a device, instrument, or substance into an unintended location or tissue. It can occur during medical procedures as well as in other settings where tools are inserted into the body or a structure. Depending on the context, misinsertion may lead to ineffective treatment, tissue injury, or other complications. The term is sometimes used interchangeably with misplacement, though some uses emphasize the entry error itself rather than post-insertion location.

In medicine, misinsertion is most discussed in relation to invasive lines, tubes, injections, and devices. Examples include nasogastric or orogastric tubes entering the airway instead of the esophagus, urethral or venous cannulation in an unintended tract, or misplacement of central venous or arterial access when the device is advanced into a wrong channel. Surgical implants or probes can also be misinserted due to distorted anatomy, poor landmarks, or device-size mismatch. Non-medical contexts include industrial or laboratory settings where components are inserted incorrectly into assemblies.

Prevention relies on training, adherence to protocols, and use of real-time guidance where feasible. Practices include imaging verification (radiographs, ultrasound, fluoroscopy) to confirm placement, physiological tests such as aspirate pH for NG tubes, use of safety features and checklists, and post-insertion confirmation before use. Prompt acknowledgment and review of any resistance or uncertainty during insertion can reduce risk.

If misinsertion is suspected or identified, the device should be stopped and removed or repositioned as appropriate, followed by verification of correct location using imaging or direct visualization. Monitoring for complications and reporting the incident as a safety event supports learning and prevention.