Is nutrition a safety issue??

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

NPSA Current ProjectsNational 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’