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Patient safety

Principle C

Poor nutritional care can threaten the safety of people in all care and community settings. The risks can be widespread, have damaging consequences and need to be understood by all nursing staff and addressed as patient safety issues.

Patient safety incidents associated with poor nutrition

The National Patient Safety Agency (NPSA) (1) collected and analysed reports of patient safety incidents received from health and social care staff in England and Wales. Through analysis of the data, the NPSA identified key themes related to food and nutritional care.

Key themes from the RLS included:

  • Dehydration: instances of dehydration on transfer of care; intravenous fluids prescribed but not administered.
  • 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) (2) has highlighted organisational factors related to enteral and parenteral nutritional including an excessive complication rate for central venous devices and feeding catheters.
  • Enteral and parenteral nutrition: the NPSA has highlighted the risk of harm from misplaced nasogastric feeding tubes in adults, children and infants (3, 4).
  • 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.

Reporting patient safety incidents associated with poor nutrition

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 (5) recommend the annual calibration of scales on all wards and in all care settings to ensure that nutritional information be included in communications on discharge from hospital and mental units.

There are tools and techniques that can reduce the risk of poor nutrition and dehydration. The engagement of patients, families and carers increases the chance of nutrition related incidents being spotted and dealt with promptly (6).

Impact of poor oral health care 

Oral health is an important factor in safe care. Poor mouth care and ill-fitting dentures will impact the ability to eat and enjoy particular types of food.