Feeding tubes, intravascular catheters, and other tubes and lines are routinely and safely used in healthcare, but tubes or lines that become dislodged can have fatal consequences, depending upon the type of tube or line used and how quickly the dislodgement is recognized and treated. But are some dislodged tubes and lines more harmful than others? Pennsylvania Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database to answer this question and others. In March 2017, the Authority published an analysis of 1,858 gastrostomy tube events reported through PA-PSRS from 2011 through 2015. Analysts identified dislodgement as the most frequently reported problem, described in 996 reports. Of these, 73 (7.3%) were reported as Serious Events resulting in patient harm, including nine deaths. Analysts reviewing these events questioned whether other dislodged tube and line types were reported to the Authority and how reports for dislodged gastrostomy tubes compared with these other types of tubes and lines, in terms of the number of events, severity of patient harm, and potential causes for dislodgement.
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