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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 6/27/2018 12:00:00 AM
Country: United Kingdom
Organization: NHS Commissioning Board
This alert discusses the patient safety incidents that can occur in patients diagnosed with dysphagia related to confusion of the many terms used to describe the need for food texture modification which is a widely accepted way of managing dysphagia. Terms for fluid thickening, such as ‘custard thickness’, have varied locally and numerical scales have been used by industry. National standard terminology for modified food texture, including terms such as ‘fork-mashable’, was agreed upon but local variations have persisted for both food and fluid texture, confusing patients, carers and healthcare staff. The imprecise term ‘soft diet’ continues to be used to refer to the modified food texture required by patients with dysphagia, and others without dysphagia, for example, with lost dentures, jaw surgery, frailty or impulsive eating. A review of National Reporting and Learning System (NRLS) incidents over a recent two-year period identified seven reports where patients appear to have come to significant harm because of confusion about the meaning of the term ‘soft diet’. These incidents included choking requiring an emergency team response, and aspiration pneumonia; two patients died. The International Dysphagia Diet Standardisation Initiative (IDDSI) has developed a standard terminology with a colour and numerical index to describe texture modification for food and drink. This alert provides links to a range of resources improvement.nhs.uk/resources/ transition-to-IDDSI-framework to assist with transition to the IDDSI framework and eliminate use of imprecise terminology, including ‘soft diet’, for all patients. Recommended actions to implement the IDDSI framework are provided.


Communication
  1. Through a local communications strategy (e.g. newsletters, local awareness campaigns etc) ensure that all relevant staff are aware of relevant IDDSI resources and importance of eliminating imprecise terminology including ‘soft diet’, and understand their role in the local implementation plan.
Rules / Policies / Procedures
  1. Identify a senior clinical leader who will bring together key individuals (including speech and language therapists, dietitians, nurses, medical staff, pharmacists and catering services) to plan and co-ordinate safe and effective local transition to the IDDSI framework and eliminate use of imprecise terminology including ‘soft diet’.
  2. Develop a local implementation plan, including revising systems for ordering diets, local training, clinical procedures and protocols, and patient information.

Resources to support safer modification of food and drink