An Algorithmic Framework for Reducing Near-Fatal Aspiration Events: A Single-Institution Experience

Aspiration-related cardiopulmonary arrests (CPAs) in hospitalized patients have a survival rate under 10%, representing a serious preventable complication. In October 2023, a multidisciplinary group of physicians, nurses, and safety specialists was formed. Review of aspiration cases from 2020 to 2024 and root cause analysis identified 3 factors: unrecognized risk, refusal of nasogastric (NG) tubes, and inconsistent application of aspiration precautions. Targeted interventions included nurse and resident education, expanded swallow screens, revised NG tubes management, and new signage to flag high-risk patients. From 2020 to 2023, there were 72 aspiration-related CPAs. Following the implementation of the countermeasures, aspiration-related CPAs decreased by 52% between 2023 and 2024 (27 events vs 13 events). Statistical process control analysis using a c-chart demonstrated a significant shift below the median with 12 consecutive points under the centerline. A multipronged, multidisciplinary approach effectively reduced fatal aspiration events, suggesting comprehensive education, improved screening, and standardized precautions can lower the incidence of aspiration-related CPAs.