| dc.description.abstract | Aims To describe the nature and causes of patient
safety incidents relating to care at home for children with
enteral feeding devices.
Methods We analysed incident data relating to
paediatric nasogastric, gastrostomy or jejunostomy
feeding at home from England and Wales’ National
Reporting and Learning System between August 2012
and July 2017. Manual screening by two authors
identified 274 incidents which met the inclusion criteria.
Each report was descriptively analysed to identify the
problems in the delivery of care, the contributory factors
and the patient outcome.
Results The most common problems in care related
to equipment and devices (n=98, 28%), procedures
and treatments (n=86, 24%), information, training and
support needs of families (n=54, 15%), feeds (n=52,
15%) and discharge from hospital (n=31, 9%). There
was a clearly stated harm to the child in 52 incidents
(19%). Contributory factors included staff/service
availability, communication between services and the
circumstances of the family carer.
Conclusions There are increasing numbers of children
who require specialist medical care at home, yet little is
known about safety in this context. This study identifies
a range of safety concerns relating to enteral feeding
which need further investigation and action. Priorities
for improvement are handovers between hospital and
community services, the training of family carers, the
provision and expertise of services in the community,
and the availability and reliability of equipment. Incident
reports capture a tiny subset of the total number of
adverse events occurring, meaning the scale of problems
will be greater than the numbers suggest. | en |
