Background Nutrition at the NPSA
• 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 TrendsReported deaths and severe harm
Pressure sores
Choking
Lack of assessment
Nil by Mouth – prolonged periods oftime
Inappropriate diet
Dehydration
Artif icial Nutrition
Naso-gastric tube
Transfer of care
Lack of assistance
Medications
Nil by Mouth – not observed
Allergy
Catering services
Delay in assessment
Delay in treatment
Discharge
Themes and TrendsReported moderate, low and no harm
Artificial nutrition
Nil by Mouth – prolonged periodof 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 harmDegree of Harm
Frequency of Reported Incidents
Actual nutrition patient safety incidents
Corrected degree of harm of Related Incidents
Death 202 20 7
Severe 395 79 3
Moderate 11 3 21
Low 80 10 40
No harm 209 37 78
Total 887 149 149
Examples of reported incidentsPatient 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 incidentsWhile …. 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
392Incidents
7Duplicate
17Inadequate information
132Met criteria
260Excluded
1General Practice
2Learning
Disabilities
29Community
Hospital
95Acute/
General
5Mental Health
29Care
Homes
2Severe harm
8Moderate
harm
16Lowharm
2No harm
0Death
3Falls
8Deterioration
1Readmission
1UrinaryTract
infection
2Medication
1Unclear
14Pressure
Ulcers
NPSA products
• 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/resources/?entryid45=59865&q=0%c2%acnutrition%c2%ac
NPSA ProductsWater for Health
Hydration Best Practice Toolkit• 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/resources/type/toolkits/?entryid45=59886
Top Related