Aspiration Pneumonia: Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of aspiration pneumonia, clinical and system reviews should be conducted to identify potential causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resources Introduction
If your review reveals that your cases of aspiration pneumonia are linked to specific processes or procedures, you may find these resources helpful:
- American Association of Critical-Care Nurses (AACN). AACN practice alert: Prevention of aspiration in adults. Critical Care Nurse (2016 - updated 2018). https://www.aacn.org/clinical-resources/practice-alerts/prevention-of-aspiration
- American Board of Swallowing and Swallowing Disorders. www.swallowingdisorders.org
- Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee - Guidelines for preventing health-care associated pneumonia. (2003) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
- Dysphagia Research Society www.dysphagiaresearch.org
- NHS Patient Safety Resources. www.nrls.npsa.nhs.uk/resources/?entryid45=59823
Aspiration Pneumonia
