Tracheostomy incidents are monitored by the National Patient Safety Agency (NPSA) and have been subject to reports by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the National Tracheostomy Safety Project (NTSP). Details of these reports can be found in the Further Reading and Activities section of the Resources page
These reports tell us that between 20 and 30% of all patients admitted to a hospital will have some sort of incident. When a clinical incident occurs relating to a tracheostomy or laryngectomy, then the chance of some harm occurring is between 60 and 70%, depending on the location in which the patient is being cared for.
Even though patients are usually less sick in ward environments, they suffer worse harm and have more frequent incidents in wards.
Question: Why do you think this might be?
Tracheostomy incidents are monitored by the National Patient Safety Agency (NPSA) and have been subject to reports by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the National Tracheostomy Safety Project (NTSP). Details of these reports can be found in the Further Reading and Activities section of the Resources page
These reports tell us that between 20 and 30% of all patients admitted to a hospital will have some sort of incident. When a clinical incident occurs relating to a tracheostomy or laryngectomy, then the chance of some harm occurring is between 60 and 70%, depending on the location in which the patient is being cared for.
Even though patients are usually less sick in ward environments, they suffer worse harm and have more frequent incidents in wards.
Question: Why do you think this might be?
Answer: This most likely reflects the different levels of staffing, monitoring, equipment and airway expertise in ward areas.
Question: What type of incidents do you think are reported to the NPSA?
Tracheostomy incidents are monitored by the National Patient Safety Agency (NPSA) and have been subject to reports by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the National Tracheostomy Safety Project (NTSP). Details of these reports can be found in the Further Reading and Activities section of the Resources page
These reports tell us that between 20 and 30% of all patients admitted to a hospital will have some sort of incident. When a clinical incident occurs relating to a tracheostomy or laryngectomy, then the chance of some harm occurring is between 60 and 70%, depending on the location in which the patient is being cared for.
Even though patients are usually less sick in ward environments, they suffer worse harm and have more frequent incidents in wards.
Question: Why do you think this might be?
Answer: This most likely reflects the different levels of staffing, monitoring, equipment and airway expertise in ward areas.
Question: What type of incidents do you think are reported to the NPSA?
Answer: Incidents can be classified as:
- Incidents at the time of performing the tracheostomy
- Blockage or displacement of the tracheostomy after placement
- Equipment incidents
- Competency (skills and knowledge) incidents
- Infrastructure (staffing and location) incidents
Question: What problems do you think our patients are most concerned about?
Tracheostomy incidents are monitored by the National Patient Safety Agency (NPSA) and have been subject to reports by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the National Tracheostomy Safety Project (NTSP). Details of these reports can be found in the Further Reading and Activities section of the Resources page
These reports tell us that between 20 and 30% of all patients admitted to a hospital will have some sort of incident. When a clinical incident occurs relating to a tracheostomy or laryngectomy, then the chance of some harm occurring is between 60 and 70%, depending on the location in which the patient is being cared for.
Even though patients are usually less sick in ward environments, they suffer worse harm and have more frequent incidents in wards.
Question: Why do you think this might be?
Answer: This most likely reflects the different levels of staffing, monitoring, equipment and airway expertise in ward areas.
Question: What type of incidents do you think are reported to the NPSA?
Answer: Incidents can be classified as:
- Incidents at the time of performing the tracheostomy
- Blockage or displacement of the tracheostomy after placement
- Equipment incidents
- Competency (skills and knowledge) incidents
- Infrastructure (staffing and location) incidents
Question: What problems do you think our patients are most concerned about?
Answer: Patients assume safe care but deserve the highest possible quality of care. The NTSP has surveyed and interviewed hundreds of patients and the biggest concerns they have are:
- Losing the ability to vocalise
- Struggling to eat or drink
- The length of time they are in hospital for
- Anxieties about their care and what happens after the tracheostomy
Importantly, many incidents are predictable and preventable, as are the problems that patients consistently highlight. Individual hospitals and collaborations have shown that the frequency, nature and severity of incidents can be reduced by implementing prospective quality improvement (QI) strategies. An example of a QI collaborative is the Global Tracheostomy Collaborative (View website).