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Is poor nutritional care a safety issue?
Organisations need to realise that all aspects of nutritional care if delivered poorly have the potential to cause unnecessary harm to people in all care and community settings. The risks can be widespread and have damaging consequences.
National Patient Safety Agency report on nutrition as a safety issue
The National Patient Safety Agency (NPSA) collects and analyses reports of patient safety incidents received from health and social care staff in England and Wales. Through analysis of the data in its Reporting and Learning System (RLS), the NPSA has identified key themes of reported incidents that associated with food and nutritional care. Whilst many of these relate to hospitals, some of them are relevant to care provided in other settings, such as care homes.
Key themes from the Reporting and Learning System
Key themes from the RLS included:
- Artificial nutrition: The most frequently reported incidents were on the provision of nutrition via artificial feeding and relate to misplaced nasogastric feeding tubes in adults, children and infants. Incorrect feed types and amounts given were also reported.
- Choking: Patients or service users witnessed choking whilst eating.
- Dehydration: Instances of dehydration were reported on transfer of care. In addition, intravenous fluids prescribed but not administered.
- Nil by Mouth: Patients have been noted to being kept Nil by Mouth for prolonged periods of time whilst waiting for surgery or a special assessment.
- Inappropriate diet: Patients or service users receiving incorrect diets, including receiving meals with ingredients to which they are allergic, people with swallowing problems (dysphagia) not receiving a textured modified diet, or people receiving textured modified diets when they could eat a normal diet.
- Catering services: Meals being given at an inappropriate temperature; services being unable to provide the correct diets.
- Missed meals: Missing meals unnecessarily, for example, for a non-urgent investigation or procedure, and where catering was not/could not be organised to replace these.
- Transfer of care: Hospital patients being transferred to care homes or into the community without information relating to their nutritional requirements being given.
- Pressure ulcers: Lack of nutritional intake being a contributory factor in the development of pressure ulcers.
Dysphagia as an area of concern
The NPSA has highlighted dysphagia as an area of concern. In a 2008 RLS review, 12 death or severe harm incidents related to choking, largely because of people receiving inappropriate diets or fluids. Ten of these incidents occurred in a mental health or learning disability care environment. NPSA have further commented on the inconsistent use of language to describe texture modification, and that improvements are needed in the management of choking and delays in assessment. For example, NPSA noted delays in people being referred to speech and language therapists (the health professionals with specialist swallowing assessment skills), as well as delays in an assessment being undertaken.
A review of RLS has also highlighted patient safety incidents around hydration, with the predominant cause of dehydration described as a ‘failure to act’.
Nutrition and hydration patient safety issues continue to be under-reported in the RLS. It is important that staff work to identify safety issues and that action is taken to improve care. Incidents do not have to be immediately like threatening to be reported as a safety issue. For example, issues that should be reported include availability of equipment, such as weighing scales for nutritional screening or specialised cutlery, lack of assistance at mealtimes and lack of nutrition screening.
Through further analysis of the safety incident data, factors have emerged that impact on patient safety issues in nutrition and hydration including:
- Levels of staffing and staff training;
- Poor communication between staff;
- Inadequately kept documents regarding fluid and food requirements;
- Lack of equipment;
- Failure to follow guidelines or implement changes in plans with regards to feeding and hydration.
In the context of patient safety, there is a need to consider the systems and processes in which nutritional care and services are provided and ask whether services are designed to meet the needs of people in care, and whether they could be improved to facilitate patient safety and good nutrition.
Reliable and sustainable improvements in the provision of nutrition and hydration will help reduce avoidable harm and will improve outcomes and the experience of people using our healthcare services. Some of these improvements may require a service redesign at a local level and others (such as the safety issues in artificial feeding) may require innovations and technologies that need to be driven at a national level.