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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 7/25/2018 12:00:00 AM
Country: United Kingdom
Organization: NHS Commissioning Board

This alert discusses the patient safety incident of autonomic dysreflexia in patients with neurogenic bowel dysfunction and who depend on routine interventional bowel care, including the digital (manual) removal of faeces (DRF). Autonomic dysreflexia is characterised by a rapid rise in blood pressure, risking cerebral haemorrhage and death. It can be caused by non-adherence to a patient's usual bowel routine or during or following interventional bowel care. Review of relevant adverse events reported to the National Reporting and Learning System (NRLS) identified key contributing factors to significant delays in providing DRF or an appropriate alternative including the following: -lack of staff with the training and experience to perform DRF -unclear local policies stating who could perform DRF, including the patient’s -carers or healthcare professionals from another provider -lack of knowledge of relevant clinical guidance -uncertainty over requirement for and provision of training -uncertainty over using alternative methods of bowel management -a mistaken belief that this type of care constitutes assault. This alert provides links to a range of resources to support safer bowel care for patients at risk of autonomic dysreflexia, and highlights the publication of NHS England’s Excellence in continence care guidance 2018 which addresses how providers can overcome implementation challenges. Recommended actions are provided to implement appropriate interventional bowel management in patients with neurogenic bowel dysfunction.



Resources to support safer bowel care for patients at risk of autonomic dysreflexia