Reduction in harm from tracheostomy‐related incidents after implementation of the paediatric National Tracheostomy Safety Project resources: A retrospective analysis from a tertiary paediatric centre

Reduction in harm from tracheostomy‐related incidents after implementation of the paediatric... KeypointsNumerous studies have demonstrated the significant morbidity and mortality attributable to tracheostomy‐related patient safety incidents in the paediatric population.We have introduced a multidisciplinary tracheostomy care improvement programme across our tertiary paediatric hospital including application of the Paediatric National Tracheostomy Safety Project emergency guidelines over a 6 year period.Our retrospective review of 128 tracheostomy‐related patient safety incidents during this period has demonstrated rapid and sustained trend in reduction in harm from 57% to 26% (P = .013).Reduction in harm likely represents better recognition of appropriate long‐term and emergency management, followed by appropriate guided responses by trained staff.Future research should be directed towards observing if this sustained harm reduction is reproducible at other institutions.INTRODUCTIONIn the UK, patient safety issues related to adult tracheostomies are well recognised. A number of reports from the National Patient Safety Agency and National Confidential Enquiry into Patient Outcome and Death highlighted recurrent themes with deficiencies in staff education, resources, equipment provision and emergency guidance.Similar patient safety concerns exist in the paediatric population. Studies report overall mortality rates in paediatric patients with tracheostomies varying from 2.2% to 58.8%, whilst tracheostomy‐specific mortality is lower at 0.9% to 5.9%. Within our institution, concerns were noted regarding the risk of http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Clinical Otolaryngology Wiley

Reduction in harm from tracheostomy‐related incidents after implementation of the paediatric National Tracheostomy Safety Project resources: A retrospective analysis from a tertiary paediatric centre

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Publisher
Wiley
Copyright
© 2018 John Wiley & Sons Ltd
ISSN
1749-4478
eISSN
1749-4486
D.O.I.
10.1111/coa.12994
Publisher site
See Article on Publisher Site

Abstract

KeypointsNumerous studies have demonstrated the significant morbidity and mortality attributable to tracheostomy‐related patient safety incidents in the paediatric population.We have introduced a multidisciplinary tracheostomy care improvement programme across our tertiary paediatric hospital including application of the Paediatric National Tracheostomy Safety Project emergency guidelines over a 6 year period.Our retrospective review of 128 tracheostomy‐related patient safety incidents during this period has demonstrated rapid and sustained trend in reduction in harm from 57% to 26% (P = .013).Reduction in harm likely represents better recognition of appropriate long‐term and emergency management, followed by appropriate guided responses by trained staff.Future research should be directed towards observing if this sustained harm reduction is reproducible at other institutions.INTRODUCTIONIn the UK, patient safety issues related to adult tracheostomies are well recognised. A number of reports from the National Patient Safety Agency and National Confidential Enquiry into Patient Outcome and Death highlighted recurrent themes with deficiencies in staff education, resources, equipment provision and emergency guidance.Similar patient safety concerns exist in the paediatric population. Studies report overall mortality rates in paediatric patients with tracheostomies varying from 2.2% to 58.8%, whilst tracheostomy‐specific mortality is lower at 0.9% to 5.9%. Within our institution, concerns were noted regarding the risk of

Journal

Clinical OtolaryngologyWiley

Published: Jan 1, 2018

References

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