Problems in care | N |
Administration and documentation | 7 |
Errors in documentation | 4 |
Documentation not available | 3 |
Communication | 7 |
Communication failures between staff | 3 |
Inadequate handovers in the community | 3 |
Communication problems between staff and family | 1 |
Discharge | 31 |
Inadequate or no handover from hospital to community teams | 13 |
Required equipment, medication or feeds not supplied at discharge | 9 |
Other discharge problems | 6 |
Lack of support in the community post-discharge | 3 |
Equipment and devices | 98 |
Faulty or damaged gastrostomy and jejunostomy devices | 25 |
Faulty or damaged feeding equipment (eg, giving sets, pumps) | 24 |
Faulty or damaged NG tubes | 13 |
Equipment not available | 13 |
Incorrect equipment ordered or delivered | 7 |
Device is leaking or loose | 6 |
Equipment not delivered or delayed | 4 |
Equipment used incorrectly | 4 |
Equipment out of date | 2 |
Feeds | 52 |
Feed not given on time | 12 |
Incorrect feed or feeding regime given | 12 |
Incorrect feed ordered or delivered | 9 |
Feed given through incorrect port | 8 |
Feed not delivered or delayed | 4 |
Out of date feed delivered or administered | 3 |
Child left unattended during overnight feeding | 3 |
Feed leaking | 1 |
Information, training and support needs of families | 54 |
Family carer has not received appropriate training or information | 28 |
Family carer does not follow procedure correctly or goes against advice | 16 |
Family carer given inappropriate advice | 5 |
Lack of support for family in the community | 3 |
Family carer given conflicting information | 2 |
Medications | 16 |
Medication administered through incorrect port | 4 |
Medication inserted into balloon | 2 |
Medication not given | 2 |
Medication or prescription errors | 2 |
Wrong dose given | 2 |
Difficulties obtaining medication | 1 |
Medication blocks tube | 1 |
Medication given at wrong time | 1 |
Wrong medication given | 1 |
Procedures and treatment | 86 |
Gastrostomy button or jejunostomy device comes out | 11 |
Delays to procedure or no staff available | 11 |
Problems or complications passing NG tube | 11 |
Tube wrapped around neck during overnight feed | 6 |
Wrong length NG tube passed | 6 |
Wrong size button fitted | 6 |
Procedure not followed correctly | 6 |
Problems changing or fitting button | 5 |
Feed, water or medication put down tube without confirming position | 5 |
Complications relating to gastrostomy site | 3 |
Damage from nasal bridle | 3 |
Staff member does not have appropriate training | 3 |
Silver nitrate-related problems | 3 |
NG tube comes out | 2 |
Child pulls out feeding tube during overnight feeding | 1 |
Inappropriate treatment | 1 |
Procedure done on wrong patient | 1 |
Other | 2 |
Missed appointments or reviews | 2 |
NG, nasogastric.