Incidents and adverse events in enteral feeding tube users : warnings based on a cohort study

Abstract

Introduction: few studies clearly describe incidents or adverse events that occur during the enteral nutrition process, which hinders the identification of critical points. Objective: to describe breaches of protocol, incidents and adverse events, during the period beginning with indications until the use of enteral feeding tube in an Emergency Department. Method: trained nurses prospectively monitored a cohort of adults in a Brazilian Emergency Department where use of enteral feeding tube was indicated and up to their use. The study sought to identify breaches of protocol, such as verbal orders to insert feeding tubes, or authorization of their use without X-rays to confirm the position of the feeding tubes. Incidents were characterized as events that could have caused harm to patients, while adverse events were those that did actually cause harm. The study was approved by the institution’s Research Ethics Committee. Results: in 150 feeding tube insertions, there were 169 breaches of protocol: verbal orders for feeding tube insertion (n = 59); no X-rays taken (n = 11); and no examination of the X-rays by physicians (n = 12). There were 30 incidents: unintentional removal of the feeding tube (n = 23); and administration of enteral nutrition after breach of preventive barriers. There was one adverse event: aspiration of enteral nutrition. Conclusion: there was a high frequency of breaches of safety protocols; many developed into incidents, and one resulted in an adverse event.

Introducción: pocos estudios describen claramente los incidentes o eventos adversos que suceden durante el proceso de nutrición enteral, dificultando la identificación de puntos críticos. Objetivo: describir las rupturas de protocolo, los incidentes y los eventos adversos de la indicación para uso de sondas nasogástricas en un Servicio de Urgencias. Método: enfermeras capacitadas siguieron prospectivamente a una cohorte de adultos de un Servicio de Urgencias brasileño, con indicación de uso de sonda enteral. Se buscó identificar las rupturas de protocolo, descritas como: “orden verbal” para inserción de la sonda o para aprobar su uso; y no realización de radiografía confirmatoria del posicionamiento de la sonda. Los incidentes fueron considerados eventos que podrían haber provocado daños al paciente, mientras que los eventos adversos, como incidentes que efectivamente los provocaron. Este proyecto fue aprobado por el Comité de Ética en Investigación de la institución. Resultados: en 150 inserciones de sonda hubo 169 rupturas de protocolo: orden verbal para inserción de sonda (n = 59), no realización de radiografía (n = 11) y radiografía no evaluada por médico (n = 12). Ocurrieron 30 incidentes: retiro inadvertido de sonda (n = 23) y administración de dieta en vigencia de ruptura de barreras (n = 7). Hubo un evento adverso grave (aspiración de dieta). Conclusión: hubo elevada frecuencia de ruptura de protocolo de seguridad; muchas evolucionaron a incidentes y uno de ellos resultó evento adverso.