Nutrition - patient safety

People are at risk of malnutrition and dehydration in all care settings. These risks are widespread, have damaging consequences and need to be understood and addressed as patient safety issues.

Patient safety incidents associated with poor nutrition

We know from records maintained by the National Patient Safety Agency (NPSA) the particular kinds of patient safety incidents that are associated with the risk of malnutrition and dehydration (NPSA 2009). Some of these incidents are described below.

Dehydration: instances of dehydration on transfer of care; intravenous fluids prescribed but not adminstered.
Hydration and mobilisation reduce the risk of acquiring venous thromboembolism (VTE).
Inappropriate diet: patients or service users receiving incorrect diets, including receiving meals with ingredients to which they are allergic, people with swallowing problems not receiving a textured modified diet, or people receiving textured modified diets when they could eat a normal diet.
Missed meals: hospital patients missing meals unnecessarily, for example, leaving the ward for a non-urgent investigation or procedure.
Nil by mouth: hospital patients being kept Nil by Mouth for prolonged periods of time whilst waiting for surgery or a special assessment.
Parenteral nutrition: a recent report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has highlighted organisational factors related to enteral and parenteral nutritional including an excessive complication rate for central venous devices and feeding catheters (NCEPOD 2010).
Enteral and parenteral nutrition: the National Patient Safety Agency (NPSA) has highlighted the risk of harm from misplaced nasogastric feeding tubes in adults, children and infants (NPSA 2011; NPSA 2012).
Handwashing: the Care Quality Commission reported that patients were being denied the opportunity to wash their hands at mealtimes despite the importance of hand washing in reducing hospital acquired infections.
Pressure ulcers: lack of nutritional intake being a contributory factor in the development of pressure ulcers.
Transfer of care: hospital patients being transferred to care homes or into the community without information relating to their nutritional requirements being given.

Nursing staff need to report these and similar issues especially availability of equipment including scales and cutlery, lack of assistance at mealtimes and lack of nutritional screening. It is important that staff are encouraged to report these issues and know how to report locally. BAPEN’s report of the fourth Nutrition Week Survey undertaken in Spring 2011 (BAPEN 2012) recommends the annual calibration of scales on all wards and in all care settings and ensuring that nutritional information identified as malnourished be included in communications on discharge from hospital and mental units.

There are tools and techniques that can be introduced to reduce the risk of poor nutrition and dehydration. Protected mealtimes and red tray initiatives are part of this approach. The active engagement of patients, families and carers increases the likelihood of nutrition related incidents being spotted and dealt with promptly (Age UK 2011).

Impact of poor oral health care

Oral health is also an important factor in safe care. Poor mouth care and ill-fitting dentures will impact on nutritional intake and ability to eat particular types of food as well as enjoyment of food. Fundamentals of Care includes a practice indicator for oral health and hygiene (Welsh Assembly Government 2003). Audits carried out in hospital settings in Wales using this practice indicator have shown that mouth care has often not been well done. A programme for improving mouth care for adult patients in hospital has been established through the1000 Lives Plus initiative in Wales in order to address this (1000 Lives Plus 2012).

The Guidelines and Audit Implementation Network (GAIN) in Northern Ireland has published guidelines for the oral health care of older people in care homes for similar reasons (GAIN 2012). The introduction to the guidelines also makes the point that because increasing numbers of older people now have their own teeth staff are frequently required to support dentate patients and residents in care homes. The guideline document highlights the associations between poor oral hygiene and aspiration pneumonia “which accounts for up to 48% of all chest infections in nursing home residents” (GAIN 2012, p.6).

Case studies and good practice examples addressing some of the issues highlighted above are available at Enhancing nutritional care.

For guidance and tools to support patient safety in nutritional care see Patient safety resources.