Data Snapshot: dislodged tubes and lines
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Feil, Michelle, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, September 2017
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Catheterization -- adverse effects Catheterization -- mortality Catheters -- adverse effects Equipment Failure Equipment Safety Intubation -- adverse effects Intubation -- instrumentation Intubation -- mortality Catheterization, Peripheral -- adverse effects Catheterization, Peripheral -- instrumentation Catheterization, Peripheral -- mortality Catheters, Indwelling -- adverse effects Drainage -- adverse effects Drainage -- instrumentation Drainage -- mortality Intubation, Gastrointestinal -- adverse effects Intubation, Gastrointestinal -- instrumentation Intubation, Gastrointestinal -- mortality Patient safety Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- Feeding tubes, intravascular catheters, and other tubes and lines are routinely and safely used in healthcare, but tubes or lines that become dislodged can have fatal consequences, depending upon the type of tube or line used and how quickly the dislodgement is recognized and treated. But are some dislodged tubes and lines more harmful than others? Pennsylvania Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to answer this question and others. In March 2017, the Authority published an analysis of 1,858 gastrostomy tube events reported through PA-PSRS from 2011 through 2015. Analysts identified dislodgement as the most frequently reported problem, described in 996 reports. Of these, 73 (7.3%) were reported as Serious Events resulting in patient harm, including nine deaths. Analysts reviewing these events questioned whether other dislodged tube and line types were reported to the Authority and how reports for dislodged gastrostomy tubes compared with these other types of tubes and lines, in terms of the number of events, severity of patient harm, and potential causes for dislodgement.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Extent:
- 1 online resource (1 PDF file (8 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101715822 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101715822