1. Is nutrition a safety issue??

2. 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

3. Nutrition patient safety issues Analysis of nutrition related patient safety incident between 1 st January 2008 and 31 st 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

4. Themes and Trends Reported deaths and severe harm

5. Themes and Trends Reported moderate, low and no harm

6. Degree of harm Degree of Harm Frequency of Reported Incidents Actual nutrition patient safety incidents Corrected degree of harm of Related Incidents Death202207 Severe395793 Moderate11321 Low801040 No harm2093778 Total887149

7. 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.

8. 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

9. 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

10. 392 Incidents 7 Duplicate 17 Inadequate information 132 Met criteria 260 Excluded 1 General Practice 2 Learning Disabilities 29 Community Hospital 95 Acute/ General 5 Mental Health 29 Care Homes 2 Severe harm 8 Moderate harm 16 Low harm 2 No harm 0 Death 3 Falls 8 Deterioration 1 Readmission 1 Urinary Tract infection 2 Medication 1 Unclear 14 Pressure Ulcers

11. 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/resour ces/?entryid45=59865&q=0%c2%a cnutrition%c2%ac http://www.nrls.npsa.nhs.uk/resour ces/?entryid45=59865&q=0%c2%a cnutrition%c2%ac

12. NPSA Products Water 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/reso urces/type/toolkits/?entryid45=5 9886 http://www.nrls.npsa.nhs.uk/reso urces/type/toolkits/?entryid45=5 9886

13. 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’