OBJECTIVES: Requirement for assisted nutrition is common in healthcare and is often achieved via an enteral feeding tube (EFT). Misplacement and use of an EFT in the respiratory tract can lead to serious patient harm and is a ‘never event’ for certain national health services. Standard EFTs are placed ‘blind’ and must be confirmed by X-ray. Here, cost-benefit of an EFT with a built-in camera is estimated. METHODS: Comparison of direct visual observation (DVO) and blind EFT tube placement was performed using a decision tree. For each blind procedure, the EFT was placed correctly (pyloric 94.5% or postpyloric 60.4%), placed in the trachea (1.9%, range 1.5%-2.1%), or otherwise misplaced in the gastric tract. Misplaced EFTs were replaced, with replacement after a tracheal insertion having a misplacement rate of 32%. A mean of 1.4 and 1.8 X-rays per EFT were required to confirm pyloric and postpyloric placement, respectively. Pneumothorax incidence was 10.2% (6.9%-33.3%) after tracheal placement, with associated mortality being 14.3% (0.0%-44.4%). The DVO and standard EFTs cost $150 and $5, respectively, per tube. Confirmation X‑rays cost $150 ($100-$300). Early studies indicate that each DVO placement takes 5.5 minutes, 45% required two attempts, no severe AEs occur, and no X-ray was used in 95% of cases. RESULTS: Assuming reuse of the DVO-EFT, this methodology was cost saving. If each replacement required a new EFT, the methodology would likely be considered beneficial at a cost‑benefit threshold $10,000 per pneumothorax avoided. DVO is cost-saving in this scenario if costs for care, provider time, and ICU are considered. Other AE rates require confirmation, but pneumothorax rates could be increased and the cost-benefit of DVO would still be realized under the current model conditions. CONCLUSIONS: The incremental cost DVO is fully or partially offset by reduced X-ray use. Avoidance of radiation and saved time are additional benefits.