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Quarterly Data Summary Issue 12: Learning from reporting - is nutrition a patient safety problem?

Learning from reporting - is nutrition a patient safety problem?
Reference number
0926F2
Issue date01 May 2009
TypeData report

This learning from reporting section, taken from Quarterly Data Summary Issue 12, focuses on nutrition-related patient safety incidents reported as occurring during 2006 and 2007.

 

Of the total incidents reported, 1,433 were defined as being nutrition‑related. These were reviewed and attributed to one or more of 14 key themes. Commonly reported incidents related to the provision of nutrition via artificial feeding; incidents relating to patients being nil by mouth; and the provision of nutrition via oral feeding.

 

The feature considers:

  • a description of the data analysis and results;
  • examples of the most common nutrition‑related patient safety incidents within each aspect of nutritional care; and 
  • a description of the nutrition‑related themes.

 

It concludes that nutrition‑related patient safety incidents can occur at any stage in the patients’ journey. Key contributing factors for nutrition‑related patient safety incidents include poor communication, staffing issues and unreliable application of protocols and systems.

 

Nutrition‑related patient safety incidents are under-reported, and this should be recognised and addressed by healthcare organisations.


Quarterly Data Summary 12 learning from reporting Is nutrition a patient safety problem?
Quarterly Data Summary 12 learning from reporting Is nutrition a patient safety problem? - 400 KB 0926-F2 - Quarterly Data Summary 12 learning from reporting Is nutrition a patient safety problem? - 2009-05 - V1