An analysis of events reported to the Pennsylvania Patient Safety Authority from January 2009 through June 2014 revealed 285 dietary errors. Errors included giving patients meals that included a food item on the tray to which they were allergic (181 events), were the wrong diet (50 events) or were meant for other patients (43 events). Eleven events included delivering meals to patients who were not supposed to be given any food by mouth.
Among the nearly 300 dietary errors, eight caused serious harm to patients, according to the report.
“Delivering the right tray of food to the right patient at the right time in the acute care setting is a complicated process,” said Susan Wallace, patient safety analyst of the Pennsylvania Patient Safety Authority. “To get it right, several hospital departments and services must communicate, cooperate and function as a coordinated team.”
To help avoid dietary errors — which can occur at any point in the process, from order entry through tray delivery — the Pennsylvania Patient Safety Authority reached out to clinical dietitians and dietary directors from Pennsylvania hospitals for their expert opinions.
The experts provided five risk reduction strategies for hospitals to implement, listed below.
- Educate all healthcare workers by providing continued education and training on food allergies and special diets
- Teach healthcare workers the proper way to answer a patient’s questions and concerns
- Create a written procedure for handling food allergies and special diets for all staff members to follow
- Encourage food service employees to consistently check for two patient identifiers before giving a patient a food tray
- Require cooks and chefs to use only the ingredients listed on a recipe and avoid making substitutions
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