Patient Safety: Reducing Dietary Errors

Providing the right diet to the right patient
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Dietary errors occurred in 285 events reported to the Pennsylvania Patient Safety Authority between January 2009 and June 2014, with eight events causing serious harm to patients. The findings highlight the importance of having dietary standards to ensure that meals served in the hospital meet the needs of patients.

Meals delivered to patients who were allergic to a food item on the tray were identified as the most frequently reported type of event (64 percent of the time). The most common allergies reported were the same ones that plague much of the population: fruit, dairy, eggs and fish. Other common allergies included vegetables, wheat, tomato, peanuts and shellfish. Although most of these errors did not affect the patient’s recovery, a small percentage (about 4 percent) of patients experienced serious harm, meaning they needed intubation, emergency administration of epinephrine or another medication, or transfer to a higher level of care.

Other types of events included patients receiving the wrong diet (17 percent of the time), meals meant for other patients (15 percent), and meals delivered to patients who were not to receive any food by mouth, such as preoperative patients (4 percent).

"Delivering the right tray of food to the right patient at the right time in the acute care setting is a complicated process," Susan Wallace, MPH, CPHRM, patient safety analyst of the Pennsylvania Patient Safety Authority said. "To get it right, several hospital departments and services must communicate, cooperate and function as a coordinated team."

This research only shows the prevalence of diet-related errors in one state’s hospitals. If expanded to all 50 American states, these errors could be harming many patients each day.

There are measures that hospitals can implement to reduce the chance of these errors. For example, one hospital in Tennessee has a “diet wheel” that is placed on the door of each patient room. Nurses can set the dial on the wheel to the type of diet ordered for the patient. This makes it easier for dietary staff to double-check whether they are delivering the correct food to each patient.

Other successful strategies include placing stickers on medical records (or creating customised alerts in electronic medical records) identifying a food allergy, or giving patients colour-coded wristbands that signify specific allergies or dietary requirements.

Moreover, the Pennsylvania Patient Safety Authority has developed consumer tips for patients to become more involved in the process.

"It is important for the patient or caregiver to pay attention to meals provided in the hospital," Wallace said. "The tips provide two narratives from actual events within Pennsylvania healthcare facilities in which the patients have very different outcomes based upon the decisions they make when eating their meal while in the hospital." Patients can learn from these events as much as healthcare personnel, she added.

Source: Pennsylvania Patient Safety Authority
Image credit: Wikimedia Commons


Wallace SC (2015) Delivering the Right Diet to the Right Patient Every Time. Pa Patient Saf Advis 2015 Jun;12(2):62-70

Published on : Sun, 5 Jul 2015

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healthmanagement, diet, dietary errors, patient safety, allergies, acute care Dietary errors occurred in 285 events reported to the Pennsylvania Patient Safety Authority between January 2009 and June 2014, with eight events causing serious harm to patients.

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