Dislodged gastrostomy tubes: preventing a potentially fatal complication
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Fiel, Michelle, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, March 2017
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Enteral Nutrition -- adverse effects Enteral Nutrition -- instrumentation Equipment Failure Equipment Safety Fatal Outcome Gastrostomy -- instrumentation Patient Safety Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- A Pennsylvania healthcare facility contacted the Pennsylvania Patient Safety Authority after experiencing two events involving dislodged gastrostomy tubes that resulted in serious patient harm. Querying the Pennsylvania Patient Safety Reporting System, analysts found that healthcare facilities submitted 1,858 event reports involving gastrostomy tubes between January 2011 and December 2015. Dislodgement was the most frequently reported problem, described in 996 event reports. Of these, 73 were reported as Serious Events resulting in patient harm, with the highest level of harm (including peritonitis, sepsis, and death) reported in cases in which these tubes continued to be used for enteral feeding before providers realized that the tubes were in an improper position. Potential causes for dislodgement were described in about two-thirds of reports, with the top two causes identified as (1) patient pulling on the tube, and (2) movement of the tube during patient transfer, repositioning, or other care. Hospitals can decrease the risk for this complication by implementing best practices and risk reduction strategies to confirm proper positioning of gastrostomy tubes and to prevent, recognize, and manage dislodgement.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (pages 9-16))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101704103 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101704103