Special needs children with neurological impairments often face challenges in safely and sufficiently feeding by mouth. These children require alternative methods to maintain adequate nutritional levels (Al-Attar et al., 2012). Gastrostomy feeding tubes (G-Tubes) are an effective alternative for feeding these children, improving their nutritional status when oral feeding is insufficient or unsafe (Benner and Grim, 2012). In school settings, G-Tube feeding necessitates proper training and skill development among nursing staff to ensure patient safety and careful handling of the G-Tube procedure (Galloway, 2018). The accidental fall-out of G-Tubes, especially during nappy changing, poses significant risks (Hall, 2019). This essay examines the role of school services when a child’s G-Tube falls out accidentally, the impact on the child and family, and the involvement of acute hospital services, all in the context of NHS patient safety initiatives. The essay also discusses critical factors affecting patient safety and concludes with a review of the discussion.
Role of Special School Services When G-Tubes Accidentally Fall Out
Advanced nursing practice for special needs children emphasizes nurses’ responsibility to ensure safe care delivery in school settings. Literature evidence reports frequent accidental removals of gastrostomy buttons in schools (Hall, 2019). The safety of children with special needs is paramount, necessitating fully trained nurses to care for these children. G-Tubes retained for extended periods can accidentally be pulled out. If this occurs within the school, the nurse must act swiftly (Hall, 2019).
Immediate Nurse Actions
- Assessment: Nurses must assess the tube site for bleeding or injury to the stoma, especially in cases of aggressive pull (Kirk et al., 2014).
- Tube Examination: The nurse examines the tube for functionality. If the balloon is intact, the tube can be washed and reinserted.
- Spare Tubes: Schools should keep spare tubes to replace leaking or fallen tubes immediately (Hall, 2019).
- Temporary Fixes: In the absence of a spare tube, nurses can temporarily tape the tube to fix holes.
- Emergency Action: If there is bleeding, injury, or delay in noticing the fall, the nurse must send the child to an emergency room (Kirk et al., 2014).
- Risk Assessment: Schools must perform risk assessments and develop plans for such situations (Kirk et al., 2014).
- Regular Assessments: Regular assessments of G-Tube functionality are crucial. Issues like feeding problems, bloated stomach, vomiting, or severe pain require immediate action (Hall, 2019).
Legal and Ethical Responsibilities
The Special Educational Needs and Disabilities (SEND) and Health and Safety at Work (HSW) Act (1974) outline the responsibilities of school services and nurses in ensuring patient safety during such accidents (SEND, 2019; HSWA, 2019). Schools must report serious health and safety incidents to the Health and Safety Executive (HSE) (HSE, 2019). The Disabilities Education Act further defines the roles of special schools, emphasizing active communication between school services, families, and emergency healthcare services (Schindler et al., 2014). Ethical responsibilities include involving the patient’s family in decision-making, managing the child’s comfort, and using G-Tube protective belts and safe changing procedures to prevent accidental falls (Hall, 2019). Schools must also provide an Emergency G-Tube Kit, training on tube feeding, and emotional and social support to children and families (Al-Attar et al., 2012).
NHS Patient Safety Initiatives
The NHS defines patient safety as preventing unintended or unexpected harm during healthcare delivery. Recent initiatives emphasize creating a safe environment and continuously improving patient safety (Flott, Fontana, and Darzi, 2019).
Key NHS Initiatives
- Care Quality Commission (CQC) Standards: Previous initiatives focused on special measures during acute hospital inspections and assigning an Independent National Officer for these tasks.
- Transparency and Non-Discrimination: New strategies aim to make the NHS more transparent and prohibit discrimination based on beliefs (Richmond, 2018).
- Patient Safety Collaboratives: These programs work on learning from errors to minimize avoidable harms, increase safety, and save lives (Flott, Fontana, and Darzi, 2019).
Major NHS Improvements (2018-2019)
NHS inspections have identified areas for improvement, leading to several key advancements:
- Inspections: A more responsive and better-targeted approach to regulate standard practices (Tingle, 2019).
- Medication Errors: Increased patient and family confidence in prescribed medications (Tingle, 2019).
- Patient Safety Incident Management System (PSIMS): Designed to provide feedback and improve based on past errors (Sanchez-Graells, 2019).
- Healthcare-Acquired Infections: Aiming to reduce infections by 50% by 2020 through data collection and a system-wide approach (Sanchez-Graells, 2019).
- Safe Staffing in Special Needs Services: Focused on personalized, evidence-based practice to reduce mortality rates among special needs children (Tingle, 2019).
NHS Patient Safety Strategy
In July 2019, the NHS published a new patient safety strategy to broaden methods for obtaining, exchanging, and analyzing patient safety data. This strategy aims to develop global safety guidelines and analyze existing and new reporting systems to identify unknown risks (O’Driscoll, 2018). However, past evidence suggests poor implementation of previous strategies (Bagena and Naylor, 2018).
Role of RCPCH
The Royal College of Paediatrics and Child Health (RCPCH) provides decision support on child health and safeguards patient safety, particularly for children with special needs. RCPCH actively participates in quality improvement practices, providing support, education, and development for paediatricians, and increasing the competent workforce for children with special needs (Lachman and Muszynska, 2019).
Factors Impacting Patient Safety
The World Health Organization (WHO) identifies several factors affecting patient safety, including lack of proper nursing care, delayed investigations, communication difficulties, procedural issues, and medication errors (Bates and Singh, 2018). These factors are categorized under human factors, communication errors, and medication errors, with a significant impact on children with special needs (Scott and Shafi, 2018).
Human Factors
Human factors include inadequate nursing care, misdiagnosis, delayed treatment, and misuse of the Mental Capacity Act. Proper training and education for nurse practitioners are essential to prevent these issues (Dekker, 2016; Reale et al., 2016).
Communication Errors
Communication difficulties with children with special needs contribute to misdiagnosis. Poor interprofessional communication, communication with families and patients, and language barriers are significant factors (Simamora and Fathi, 2019).
Medication Errors
Children with special needs often receive incorrect medications or doses. Nurses may lack knowledge or familiarity with specific medications, posing serious threats to patient safety (WHO, 2016; Guise et al., 2015; Goedecke et al., 2016).
Conclusion
The safety of children with special needs is of paramount importance, requiring fully trained nurses in school settings. NHS patient safety initiatives, including Patient Safety Collaboratives, aim to learn from errors and identify unknown risks to enhance patient safety. Effective communication, proper training, and adherence to safety guidelines are crucial in ensuring the well-being of special needs children in schools.
References
Al-Attar, H., Shergill, A. K., Brown, N. E., Guernsey, C., Fisher, D., Temple, M., … & Connolly, B. L. (2012). Percutaneous gastrostomy tubes in children with Pierre Robin sequence: efficacy, maintenance and complications. Pediatric radiology, 42(5), 566-573.
Bagenal, J., & Naylor, A. (2018). Harnessing the value of NHS patient data. The Lancet, 392(10163), 2420-2422.
Bates, D. W., & Singh, H. (2018). Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Affairs, 37(11), 1736-1743.
Benner, S. M., & Grim, J. (2012). Assessment of young children with special needs: A context-based approach. Routledge.
Dekker, S. (2016). Patient safety: a human factors approach. CRC Press.
Flott, K., Fontana, G., & Darzi, A. (2019). The global state of patient safety.
Galloway, D. (2018). Schools, pupils and special educational needs. Routledge.
Guise, J. M., Meckler, G., O’Brien, K., Curry, M., Engle, P., Dickinson, C., … & Lambert, W. (2015). Patient safety perceptions in pediatric out-of-hospital emergency care: children’s safety initiative. The Journal of pediatrics, 167(5), 1143-1148.
Goedecke, T., Ord, K., Newbould, V., Brosch, S., & Arlett, P. (2016). Medication errors: new EU good practice guide on risk minimisation and error prevention. Drug safety, 39(6), 491-500.
Hall, K. (2019). Pediatric Discharge G-Tube Toolkit.
HSE. (2019). Health and safety for school children. Retrieved 20 December 2019, from https://www.gov.uk/health-safety-school-children
HSWA. (2019). Health and Safety at Work etc Act 1974 – legislation explained. Retrieved 20 December 2019, from https://www.hse.gov.uk/legislation/hswa.htm
Kirk, L., Shelley, A., Battles, M., & Latty, C. (2014). Educating parents on gastrostomy devices: necessary components to achieve success. Journal of pediatric nursing, 29(5), 457-465.
Lachman, P., & Muszynska, K. (2019). OC19 Changing the safety paradigm–bringing situation awareness to the fore.
NHS. (2019). The NHS Patient Safety Strategy | NHS Improvement. Retrieved 20 December 2019, from https://improvement.nhs.uk/resources/patient-safety-strategy/
Improvement Hub. (2019). Improvement Hub | Tools, resources and ideas from across the health sector | NHS Improvement. Retrieved 20 December 2019, from https://improvement.nhs.uk/improvement-hub/
O’Driscoll, M., Allan, H., Liu, L., Corbett, K., & Serrant, L. (2018). Compassion in practice—Evaluating the awareness, involvement and perceived impact of a national nursing and midwifery strategy amongst healthcare professionals in NHS Trusts in England. Journal of clinical nursing, 27(5-6), e1097-e1109.
Reale, C., Saleem, J. J., Patterson, E. S., Hettinger, A. Z., Anders, S., & Miller, A. (2016, September). Promoting Patient Safety with Human Factors Methods: Practical Approaches to Current Medication Management Issues. In Proceedings of the Human Factors and Ergonomics Society Annual Meeting (Vol. 60, No. 1, pp. 647-651). Sage CA: Los Angeles, CA: SAGE Publications.
Richmond, J. G. (2018). Unlearning and Patient Safety. In Managing Improvement in Healthcare (pp. 117-134). Palgrave Macmillan, Cham.
SANCHEZ-GRAELLS, D. A. (2019). Centralisation of procurement and supply chain management in the English NHS: some governance and compliance challenges. NILQ, 70(1), 53-75.
Schindler, C. A., Pordes, E. S., Finkenbinder, S. D., & Lee, K. J. (2019). Safety in Children With Medical Complexity: Our Canaries in the Coal Mine?. Current Treatment Options in Pediatrics, 5(2), 165-182.
Scott, D., & Shafi, M. (2018). The WHO surgical checklist: improving safety in our operating theatres. Obstetrics, Gynaecology & Reproductive Medicine, 28(9), 295-297.
Simamora, R. H., & Fathi, A. (2019). The Influence of Training Handover based SBAR Communication for Improving Patients Safety. Indian journal of public health research & development, 10(9).
Tingle, J. (2019). Improving NHS trusts’ learning from patient deaths. British Journal of Nursing, 28(7), 474-475. World Health Organization. (2016). Medication errors.
