In March 2010 the NPSA issued a Rapid Response Report (RRR) Early detection of complications after gastrostomy that focused on the first 72 hours after a gastrostomy was created. This Signal describes additional patient safety issues related to established gastrostomies in hospital and community settings.
“Called to [ward] to replace patient button [day 1].....it was impossible to pass the actual button. Needed Entonox. Definite resistance to passage of button, then suddenly it was in. Aspirated 3 ml of 'gastric juice'. Home. Overnight gastrostomy feed uncomfortable, stopped. Further feed. Eventually collapsed on [day 2]. Op [day 3].”
Where force is used to replace the button, there is potential to penetrate the abdominal cavity; if feeding via the gastrostomy is resumed this can cause a potentially fatal chemical peritonitis. Although this is the only such incident identified through reports to the NRLS made between 1st October 2007 and 10th October 2011, it underlines the importance of performing checks for correct placement when any trauma is caused during button replacement.
Trauma can also be caused during removal; in the same period we found 32 incidents describing gastrostomy tubes or buttons that had been accidentally removed with their retaining balloons or devices intact. If this happens, there could be trauma to the stoma and a risk of feed leaking into the abdomen, but staff and carers did not appear to consider this possibility and assumed it was safe to continue feeding as long as a new device could be inserted.
Additionally, although the need for rapid replacement of at least a temporary tube to stop the stoma closing was known to carers, they sometimes had no spare device to hand. When carers sought advice from urgent care services, staff seemed unaware how quickly the stoma could close, and sometimes advised carers to wait until the following day, potentially resulting in unnecessary extra invasive procedures for the patient.
Local organisations may wish to use this Signal to:
• ensure their advice to staff and carers is clear on what checks need to take place if any trauma to the stoma could have occurred during reinsertion or accidental removal;
• remind staff and carers to always take a temporary replacement tube with the patient wherever they go;
• remind staff that that if the stoma is not protected with at least a temporary replacement tube, it can close within hours.
We would like to hear from you - please contact us with your initiatives to reduce risks in this area.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.