Death by Choking on the Wrong Meal: Could it Happen at Your Place A Risk Management Approach

1
Death by Choking on the Wrong Meal Could it
Happen at Your Place? A Risk Management Approach
K. Watson, C. Bryant J. Sweeney Speech
Pathology Department in collaboration with
Nutrition and Dietetic and Food Service
Departments Austin Health, Melbourne, Australia
Results There were no significant differences
between mealtime or site when comparing pre-
post-audits. Distribution of audited meals by
audit date
Introduction Incorrect provision of texture
modified diet/fluids (TMD/F) to a patient with
dysphagia can lead to a critical incident,
choking even death. Two coronial inquests from
South Australia1-2, where a patient residents
deaths were as a result of asphyxiation from the
incorrect provision of TMD/F, led to an
investigation at Austin Health Aim 100 of
patients at Austin Hospital Heidelberg
Repatriation Hospital receive the correct TMD/F
as recommended by treating speech pathologist (SP)

• Meal provision process at Austin Health
• Complex process (16 - 30 steps) including
• Speech pathologist (SP) recommends texture
  modified diet/fluids (TMD/F), notifies dietitian
  via computer lanpaging system
• Dietitian acknowledges notification, enters
  change onto electronic meal ordering system
  (EMOS)
• Menu monitors print patient lists at specified
  times notifying them of patients current meal
  requirements
• Requirements written onto meal tickets given to
  food service assistants
• Food Service Assistants plate meals
• Meals delivered to wards

• Methods
• Creation of process map, tracking TMD/F from when
  recommended by SP to arrival at patients bedside
• Pre-audit at 4 points in the TMD/F provision
  process
• SP recommendations match meal received
• SP recommendations match electronic meal ordering
  system (EMOS)
• EMOS matches meal received
• Presence of TMD/F alerts at the bedside
• Identification of errors in the TMD/F provision
  process
• Benchmarking with 8 Melbourne metropolitan
  hospitals to scope practice around errors
  identified
• Changes implemented around identified errors in
  process
• Post-audit at 4 points in the TMD/F provision
  process

Values presented are N (percentage) P value
related to chi-squared test for difference
between audits
SP recommendations match EMOS
SP recommendations match meal received
Presence of TMD/F alerts at the bedside
EMOS matches meal received
Outcomes
References 1.Coroners Report of South Australia,
Finding of Inquest Maiolo G. 7 April 1997 and 8
May 1997 pp 1-11. 2.Coroners Report of South
Australia, Finding of Inquest Damianou D. 2
August 2005, 3 August 2005, 15 November 2005 pp
1-14. Contact kate.watson_at_austin.org.au Austin
Hospital, P.O Box 5555, Heidelberg, Victoria,
Australia, 3084 Acknowledgements Nutrition
Dietetics Department and Food Services
Department, Austin Health, Melbourne, Victoria
Conclusion The use of a risk management approach
to redesign TMD/F provision process resulted in
14 (78-89) improvement of correct meals being
provided across Austin Hospital Heidelberg
Repatriation Hospital

• Future Directions
• Further improve processes at Heidelberg
  Repatriation Hospital through engagement of Menu
  Monitors new Food Services Manager
• Educate nursing staff, combining new processes /
  implementation of Australian standardised TMD/F
  terminology
• Formalise use of incident reporting system for
  incorrect provision of TMD/F
• Review multidisciplinary policies procedures
  related to TMD/F provision process