Practice Safety Alerts

Early detection of complications after gastrostomy: summary of a safety report from the National Patient Safety Agency

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c2160 (Published 04 May 2010) Cite this as: BMJ 2010;340:c2160
  1. Frances Healey, head of patient safety for medical specialties1,
  2. David S Sanders, consultant gastroenterologist2,
  3. Tara Lamont, head of response1,
  4. John Scarpello, deputy medical director1,
  5. Taofikat Agbabiaka, research associate1
  1. 1National Reporting and Learning Service, National Patient Safety Agency, London W1T 5HD
  2. 2Department of Gastroenterology, Royal Hallamshire Hospital and the University of Sheffield, Sheffield
  1. Correspondence to: F Healey frances.healey{at}npsa.nhs.uk

    Why read this summary?

    Gastrostomies are used as a medium to long term feeding strategy for children and adults with additional dietary needs or an inability to swallow, and they may be inserted surgically, endoscopically, or under radiological guidance. About 15 000 gastrostomies are inserted annually in the United Kingdom.1 Complications include chemical peritonitis, infection, bowel perforation, haemorrhage, and aspiration pneumonia. But early recognition and prompt action reduces the risk of serious harm or death.2 Over six years (October 2003 to January 2010) the National Patient Safety Agency (NPSA) received 22 reports (including five incidents in children) from clinical staff of harm from delayed response to serious complications after gastrostomy insertion. Eleven patients died and 11 became critically ill. Reported complications included nine cases of leakage of feed into the peritoneal cavity and/or peritonitis, three colonic punctures, and two complications related to haemorrhage; under-reporting is likely.3

    Incidents were reported from settings that included general medical, surgical, and elderly care wards after gastrostomy insertion in an endoscopy or radiology unit; patients whose gastrostomy had been inserted in a day case unit sometimes returned to the unit or presented …

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