Patient Safety Topics

There continues to be a need to optimize a preliminary bedside aspiration screening that accurately predicts patients who need further testing to diagnose dysphagia, aspiration, and/or silent aspiration. The need for organizations to have more standardized aspiration screening and assessments is a priority when identifying patients with swallowing difficulties and those at risk for aspiration and silent aspiration upon admission.

Key Data and Statistics

​Patients who aspirate are at greater risk of developing serious respiratory complications such as airway obstruction or aspiration pneumonia. Patient conditions that present a high risk for aspiration include stroke or other neurologic impairment that affects swallowing, tracheostomy or endotracheal intubation, advanced age, changes in the oropharyngeal anatomy due to trauma, surgery complications, neoplasm, pneumonia, unexplained weight loss, or even body position.

Of the 133 nonanesthesia aspiration Incidents and Serious Events reported to the Pennsylvania Patient Safety Authority’s reporting system from June 2004 through January 2009, 73 (55%) of the events indicated that patients had been assessed for aspiration risk before the nonanesthesia aspiration event. Fifteen (11%) of the aspiration events required transfers to a higher level of care, and 7 (5%) resulted in patient death.

Events that resulted in transfer to higher levels of care include the following:

The patient began to cough, followed by vomiting, developed worsening respiratory symptoms, and was transferred to the ICU [intensive care unit] with shortness of breath and aspiration.

The patient was found with cyanotic face and lips upon entering the room to complete an assessment. The rapid response team was called. The patient began coughing up whole pieces of chicken. The patient was transferred to the ICU.

The patient was eating a sandwich and began to choke. Heimlich attempts were unsuccessful. The food particles [were manually] removed, and the patient [was transferred to the ICU] and intubated.

Events that resulted in patient deaths include the following:

A patient vomited during the night and [the order to administer the patient nothing by mouth] NPO [was written]. In the morning [the patient was] found unresponsive. Despite aggressive resuscitation [efforts], the patient ceased to breathe. Silent aspiration is considered the cause of death.

A patient had moderate to severe dysphagia [following a] stroke. Family [members] brought in solid food, which the patient ate and [immediately began] to choke. Despite immediate resuscitation efforts, the patient expired.

A patient with recent history of stroke was placed on pureed dysphagia diet after nutrition and speech evaluations. After being fed [a meal] by [a family member], the patient became [short of breath]. Suctioning [the patient] produced the [meal] contents. The patient was intubated, transferred to the cardiac care unit, [and died as a result] of aspiration.

The remaining 60 (45%) reports of nonanesthesia aspiration indicated patients had not received aspiration risk screening or assessments before the aspiration events.

Of the 55% of reports indicating patients had been assessed for aspiration risk before a nonanethesia aspiration event, analysis identified the following contributing factors:

  • Patients received inappropriate nutrition in 28 (38%) of the events, including delivery of incorrect nutrition to patients who were NPO (nothing by mouth), family members who fed patients who were NPO, or missed patient bedside NPO alerts.
  • Miscommunication occurred between healthcare providers and departments in the hospital in four (5%) of the events (e.g., NPO notification between patient care areas and the dietary department).
  • Medication-related issues were evident in three (4%) of the events, including some patients who received unauthorized medication doses and incidence of staff knowledge deficit (e.g., NPO clarification between prescribers and nurses when patients are NPO except for medications versus exclusively NPO).
  • Tubing insertion misplacement issues occurred in three (4%) of the events involving endotracheal, nasogastric, or gastrostomy tubes.

Excerpted from: Does your admission screening adequately predict aspiration risk? Pa Patient Saf Advis 2009 Dec.

Educational Tools

​Massey Bedside Swallowing Screen
This swallowing screening tool may be used as the preliminary screening of a patient’s swallowing abilities.


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