This Patient Safety Supplement aims to raise awareness among HSE and HSE funded healthcare services and staff on the occurrence of choking incidents in adults. Choking occurs when a blockage occurs in the upper airway and prevents a person from breathing effectively. When the blockage is partial, the person may cough incessantly to try to expel the blockage. However, a full blockage of the airway can prevent the person from breathing and coughing, resulting in ‘silent choking’. Choking incidents can lead to injury, hospitalisation and death.
This supplement will focus on supporting staff to help minimise the risk of choking in adults from food, liquids or medicine and advise staff on how to respond effectively to a choking incident. The focus of this supplement is on accidental choking events however if you suspect that a person has made a deliberate attempt to harm themselves through choking, ensure the appropriate follow-up, referrals and support are provided. The supplement integrates the human rights values embedded in the recent Assisted Decision Making (ADM) (Capacity) Act 2015 and HSE Consent Policy 2022 to support the person’s involvement in their own care when measures to reduce their risk of choking are discussed and/or introduced.
Read the full supplement
This Patient Safety Supplement aims to raise awareness among HSE and HSE funded healthcare services and staff on the occurrence of choking incidents in adults. Choking occurs when a blockage occurs in the upper airway and prevents a person from breathing effectively. When the blockage is partial, the person may cough incessantly to try to expel the blockage. However, a full blockage of the airway can prevent the person from breathing and coughing, resulting in ‘silent choking’. Choking incidents can lead to injury, hospitalisation and death.
Incident data has demonstrated that choking is a recurrent type of incident being reported with potential catastrophic consequences. The presence of dysphagia (difficulty in swallowing), caused by another diagnosis such as dementia, stroke, Parkinson's disease, mental health difficulties or intellectual disability can increase risk of both aspiration (the inhalation of food, drink, secretions into the lungs) and choking. Aspiration is not commonly reported as an incident but it is recognised that the impact of aspiration can also be serious.
What is incident data telling us?
Choking related incidents and near misses from 2020-2024 reported to the National Incident Management System (NIMS) shows that in HSE and HSE funded services;
- > 3,000 choking incidents/near misses were reported
- > 70% occurred in non-acute services in care of the older person, mental health services and disability services
- > 80% were related to food and drink
- Approximately 3% of reported incidents were related to medication
- > 1,000 incidents required first-aid or medical treatment
- 20 incidents resulted in an outcome of death as a result of choking.
Common themes highlighted included:
- occurrence of choking during eating or drinking
- use of incorrect diet consistency (as per eating and drinking plan)
- e.g. eating regular diet when soft and bite-sized diet is prescribed
- choking during medication administration
Please note that NIMS data is subject to data anomalies described in the HSE NIMS Data Quality Statement, which can be found here
What is the purpose of this Patient Safety Supplement?
This supplement will focus on supporting staff to help minimise the risk of choking in adults from food, liquids or medicine and advise staff on how to respond effectively to a choking incident. The focus of this supplement is on accidental choking events however if you suspect that a person has made a deliberate attempt to harm themselves through choking, ensure the appropriate follow-up, referrals and support are provided. The supplement integrates the human rights values embedded in the recent Assisted Decision Making (ADM) (Capacity) Act 2015 and HSE Consent Policy 2022 to support the person’s involvement in their own care when measures to reduce their risk of choking are discussed and/or introduced.
The below story illustrates how a staff member helps to reduce the risk of a choking incident occurring while integrating human rights values to support a resident to be involved in decisions about their own care.
Fiona’s Story
Fiona is a staff nurse working in a community nursing unit. One of the residents, Tony, has recently developed issues with swallowing associated with eating and drinking. With Tony’s consent he was assessed by the Speech and Language Therapist (SLT) and then agreed to an eating and drinking plan with the multidisciplinary team (MDT) to address his needs and to minimise the risk of choking.
Tony’s new eating and drinking care plan was recorded in his healthcare record (HCR) and communicated to all staff looking after Tony’s needs, and with his consent communicated to his family. One of the agreed actions was that Tony would sit fully upright while eating and drinking to help prevent choking. One evening Tony informs Fiona that he would like to discuss the option of eating his supper in bed, as he is quite tired when supper is served. Fiona is fully committed to supporting Tony in making his own decisions but is aware that Tony’s care plan details how meals should be eaten in a fully upright position to help prevent the risk of injury or serious harm from choking.
Fiona spends time with Tony talking about his request and reminds him of the increased risks of choking if he eats his supper in bed in a semi-upright position. Fiona suggests to Tony that he continues to eat his meal at the table and with Tony’s consent the SLT will be contacted to speak with him about his concerns and carry out a dysphagia reassessment if needed. Tony agrees to this suggestion and Fiona records the conversation in his HCR.
Following the meeting with Tony and the SLT a plan was reached with the agreement of the MDT that Tony’s supper would be served 30 minutes earlier each evening, before he gets tired. The change to mealtimes would be evaluated after a couple of weeks to see if it was making a positive difference for Tony. Tony’s care plan was updated. The change was recorded in his HCR and communicated to all relevant staff and to his family with his consent.
This example is service user specific. For others, in particular in acute settings, eating and drinking sitting out of bed may not be possible. Other risk mitigations will be applied.
Reducing and managing the risk of choking in adults
Decision making
- Decisions informed by prioritising safety and reducing the risk of harm
- Involve person and obtain their consent in shared decisions with support from family/supporters if requested
- All actions must be underpinned by shared and/or assisted decision making (1), consent (2) and a human rights approach
- Seek MDT input regarding requests to deviate from existing care plans
- When a person chooses to eat and drink in a way that carries increased risk, ensure a supported decision-making process (2) is followed, documented, and reviewed regularly
Identification and Assessment
- Identify choking risk e.g. polypharmacy, drowsiness, rapid eating, absent dentition (teeth / dentures)
- Review prescribed medicine list to identify if form of medication is a risk (i.e. tablet or fluid)
- Refer* to Speech and Language Therapist (SLT), Dietitian, Occupational Therapist (OT), Pharmacist and Clinicians as needed
- Multidisciplinary Team (MDT) gathers information and carries out assessment(s) as needed
- Assessment findings are discussed with person and MDT as required including Social Care Staff, Healthcare Assistants, Key Workers, Catering and Kitchen Staff
- Complete dysphagia reassessment as needed, be alert for changes that impact choking risk
Communication
- Maintain comprehensive and up to date records to include choking risk, referrals, eating and drinking plans, assessments, administration of medication and any incidents or near misses
- Share updated eating and drinking plans/prescriptions with family and all relevant staff
- Ensure protocols define how care plans are shared, including with new, agency and relief staff and during transition of care – e.g. hospital to nursing home, respite care, day services
- Develop a plan to share learning from choking incidents, near misses and audits
Risk Reduction
- People at risk of choking are supervised when eating, drinking, and taking medications. The level of supervision required is clearly defined and documented (including in staff rotas).
- Eating and drinking plans are formulated by person and SLT with relevant MDT members
- If the form of a medication requires changing (crushing or mixing with food), consult with the medical team, pharmacist and, if necessary, SLT to discuss alternative preparations or forms of administration. All changes are documented in the medications administration chart
- Ensure care plans account for times of increased risk of choking such as during meal times and medication administration, and when there are reduced staffing levels, staff who are unfamiliar with the person, visitors who are unaware of, or don’t follow care plans and when transferring the person between services
- Staff (including agency/relief staff) education and training on choking should be up to date, including policies and guidelines, related HSELand training, IDSSI (3) training and individualised training from SLT (where appropriate) on implementing the person’s care plans
- Ensure good oral hygiene and regular dental appointments are maintained
- Environmental modifications are completed with relevant MDT e.g. seating assessment by OT
- Regular clinical audits of local management of dysphagia and choking are completed
- Address and monitor any deficits identified through quality improvement plans
Responding and Reporting
- All staff and volunteers should know, and be observant for the Universal Signs of Choking:
- One or both hands clutched to the throat
- A look of panic, shock or confusion
- Inability to talk
- Strained or noisy breathing or squeaky sounds when trying to breathe
- Cough, which may either be weak or forceful
- Skin, lips and nails that turn blue or grey
- Loss of consciousness
- If an incident occurs make the person/area safe
- Complete a medical assessment and attend to the person’s clinical and care needs
- Provide support to all those involved including staff and others present
- Report the incident on NIMS (4) and manage as per the HSE Incident Management Framework (5) and Open Disclosure Policy (6). (related training (7) is available)
- Keep training in Basic Life Support including recognising/responding to choking up-to-date
*Please see Appendix 1 for when SLT support is not available or is declined
1. Assisted Decision Making (Capacity) Act 2015 / 2. HSE National Consent Policy / 3. IDDSI-International Dysphagia Diet Standardisation Initiative / 4. National Incident Management System / 5. HSE Incident Management Framework / 6. HSE Open Disclosure Policy / 7. Contact QPSIM@hse.ie
Where can I get more information?
Refer to and follow any local guidance or policies on identifying and managing dysphagia
For additional information, please see:
Assisted Decision Making (Capacity) Act 2015
Food, Nutrition and Hydration Policy for Adults Accessing Disability Services 2020
Guidance for Registered Nurse and Midwives on Medication Administration (2020)
High Risk Choking Foods Poster
HSE Food Nutrition and Hydration Policy for Adult Patients in Acute Hospitals.
HSE Incident Management Framework
HSE National Consent Policy 2022
The International Dysphagia Diet Standardisation Initiative (IDDSI)
IDDSI is the recommended framework for food and fluid modification developed through international collaboration. It has been adopted by the Irish Association of Speech and Language Therapists (IASLT) and the Irish Nutrition and Dietetic Institute (INDI). It is also endorsed for use by the HSE and the Irish Institute of Pharmacy.
This Patient Safety Supplement was co-developed by:
- National Health & Social Care Professions Office – Speech and Language Therapist and Dietitian Representation
- Office of Nursing and Midwifery Services Director – Care of the Older Person Services
- Sage Advocacy - National Advocacy Service for Older People
- QPS Team, Integrated Health Area Dublin South & Wicklow Community Services
- National Medication Safety Programme, National Quality and Patient Safety (NQPS), HSE
- Patient Safety Together, NQPS, HSE
Approved for publication by the HSE National Patient Safety Alert Committee, the National Clinical Lead, NQPS and the Chief Clinical Officer, HSE.
For further information on Patient Safety Supplements, see www.hse.ie/pst
All feedback on content or format of this supplement is welcome and can be sent to patientsafetytogether@hse.ie
Appendix 1: What to consider if Speech and Language Therapy is not available or when a person declines the services of an SLT or decides not to follow SLT recommendations or advice
When SLT is not available
- People at risk of choking are supervised when eating, drinking and taking medications
- Advise the person to avoid high risk choking foods - e.g. Hard foods (e.g. boiled sweets and nuts), crumbly foods (e.g. biscuits), tough or chewy foods (e.g. steak), round or long shaped foods (e.g. sausages, grapes), hard chunks (e.g. pieces of apple), stringy food (rhubarb, beans, celery)
- Keep staff training in Basic Life Support, including responding to choking incidents, up to date
- Ensure all staff / volunteers know and are always observant for the universal signs of choking
- Staff should avail of online HSELand training on
- Introduction to the International Dysphagia Diet Standardisation Initiative (IDDSI) Framework (45 minutes)
- The safe management of people with dysphagia (45 minutes)
- Guide to using Malnutrition Risk Screening Tools for Health Service Staff (65mins)
- Signs and symptoms of dysphagia should be acted on and escalated for each person
- For care of the older person consider referral to the affiliated Integrated Care Programme for Older Persons (ICPOP) to check for available SLT support
- Manage any choking incidents or near misses as per the Incident Management Framework and Open Disclosure Policy, including reporting on NIMS
- Provide support to all those involved in choking incidents or near misses
- Manage and escalate the risk of harm to the person of not having access to SLT, including recording on your local risk register, and managing as per local policy
- Complete a medical assessment on the person following a choking incident
When a person declines SLT services or decides not to follow SLT recommendations or advice
- Take time to support the person in understanding the purpose and potential benefits of the SLT referral and/or recommendations, and the associated risks of not accepting support
- Provide the person with information in a way they can understand and ensures that their will and preferences are respected in line with the principles of the Assisted Decision-Making (Capacity) Act 2015
- With the person’s consent, involve members of their support network to aid in decision-making
- Document all conversations and decisions in the person’s Healthcare Record