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Is nutrition a safety issue??
Background
Nutrition at the NPSA
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2006 – Nutrition and Cleaning Team
established - now part of the Primary Care,
Ambulances and Clinical Specialists Team
Since 2006 establishing the evidence that
nutrition is a patient safety issue
Working in collaboration with key
stakeholders, private sector providers and
government
Projects have included
– Protected Mealtimes Review
– Barriers to Nutritional Screening
– Water for Health Best Practice Toolkit
– 10 Key Characteristic’s to Good
Nutritional Care Toolkit
Mainly focused on the acute/hospital
environment
Nutrition patient safety issues
• Analysis of nutrition related patient safety incident
between 1st January 2008 and 31st December 2008
• Using free text word searches
• All incidents reported as death and severe harm –
597
• A sample of 300 incidents reported as moderate,
low or no harm – from a pool of 38,437 incidents
• Following analysis approx 20% of the incidents
were identified as nutrition related patient safety
incidents
Themes and Trends
Reported deaths and severe harm
Pressure sores
Choking
Lack of assessment
Nil by Mouth – prolonged periods of
time
Inappropriate diet
Dehydration
A rtif icial Nutrition
Naso-gastric tube
Transf er of care
Lack of assistance
Medications
Nil by Mouth – not observed
A llergy
Catering services
Delay
in assessment
Delay in treatment
Discharge
Themes and Trends
Reported moderate, low and no harm
Artificial nutrition
Nil by Mouth – prolonged period
of time
Inappropriate diet
Lack of assessment
Nil by Mouth – not observed
Choking
Catering services
Missed meals
Pressure sores
Dehydration
Nasogastric tube
Weighing Scales
Degree of harm
Degree of
Harm
Frequency of
Reported
Incidents
Actual
nutrition
patient safety
incidents
Corrected
degree of harm
of Related
Incidents
Death
Severe
Moderate
Low
No harm
Total
202
395
11
80
209
887
20
79
3
10
37
149
7
3
21
40
78
149
Examples of reported incidents
Patient admitted with C - spine fracture and Halo jacket (external fixation)
applied on …. . Patient found to have developed Grade III - IV pressure
sore on his back (thoracic spine) when the Halo jacket was insitu .
Pressure sore found when Patient had the Halo jacket removed, Wound
Team involved, photos taken. Patient is malnourished and underweight
- prominent pressure areas as bony prominence are vulnerable to
pressure damage. Appropriate dressing done, Dietician involved.
Patient advised to avoid lying on the affected areas, repose mattress
provided and to continue monitoring
.
Examples of reported incidents
While …. was eating his tea under supervision , he started to
choke . Staff tried to dislodge the piece of food without
success. CPR commenced and a pulse was maintained till the
paramedics arrived. …… was then
taken to …. where he died .
Patient admitted under cancer care. Developed swallowing
difficulties and was unable to tolerate fluids. Patient kept
nil by mouth awaiting Speech and Language Therapy
review. No Speech and Language Therapy services
funded for cancer care. Patient has had to wait 10 days
without eating or drinking still awaiting review
Care Home Dehydration
Analysis
• RLS data from 01 April 2008 to 31 March
2009
• Search terms – dehydration, de-hydration
• 392 incidents analysed
• 132 relevant to dehydration
• 29 relevant to care homes
392
Incidents
7
Duplicate
1
General
Practice
132
Met criteria
17
Inadequate
information
2
Learning
Disabilities
29
Community
Hospital
95
Acute/
General
260
Excluded
5
Mental
Health
29
Care
Homes
0
Death
14
Pressure
Ulcers
2
Severe
harm
3
Falls
8
Moderate
harm
8
Deterioration
1
Readmission
16
Low
harm
2
No harm
1
Urinary
Tract
infection
1
Unclear
2
Medication
NPSA products
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10 Key Characteristics of Good
Nutritional Care launched at NACC
Conference
Toolkit to assist in implementation
– 10 fact sheets launched in April
2009
– Collaborative working with the
private sector and key stakeholder
organisations
– Available at
http://www.nrls.npsa.nhs.uk/resour
ces/?entryid45=59865&q=0%c2%a
cnutrition%c2%ac
NPSA Products
Water for Health
Hydration Best Practice Toolkit
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To raise awareness of the
‘Water for Health Best
Practice Toolkit’
Encourage collaborative
working between catering
and nursing teams
Hydration Best Practice Awards
Available at
http://www.nrls.npsa.nhs.uk/reso
urces/type/toolkits/?entryid45=5
9886
NPSA Current Projects
National signage for textured
modified diets
• Promote the use of the
‘National Descriptors for
Texture Modification in
Adults’
• Move away from
ambiguous phrases – for
example: ‘custard like,
mashable and sloppy diet’