CARDINAL HEALTH

Description of Event or Problem

The customer reported the patient was found to have a Dobhoff feeding tube with the stylet still in place several days after placement which led to dehydration and hyponatremia. Per the customer, while the metal stylet is essential for placement of the tube, removal of the stylet is a challenge. The stylet plastic tip is the very same color as the ports on the feeding tube and can be difficult to differentiate easily for users. There are two ports, so inexperienced users may think the stylet is supposed to be there and use the smaller port, restricting the flow rate of feeds and fluids. Per additional information provided on July 21, 2026, the treatment for dehydration was IV fluids x 24hours. There was no treatment provided for the hyponatremia which resolved prior to discharge, monitoring only. The tube was in place for 5 days before the stylet was found to still be in the tube. The stylet was removed and the tube remained in place with placement confirmed by x-ray.