Advisory highlights risk of dietary errors


Dietary errors occurred in 285 events reported to the Pennsylvania Patient Safety Authority with eight events causing serious harm to patients, according to a June Pennsylvania Patient Safety Advisory article.

Analysis of events reported to the Pennsylvania Patient Safety Authority from January 2009 through June 2014 showed meals delivered to patients who were allergic to a food item on the tray were identified as the most frequently reported type of event. Other types of events included patients receiving the wrong diet, meals meant for other patients, and meals delivered to patients who were not to receive any food by mouth.

"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, 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.

"As the Authority data shows, a dietary error can occur at any point in the dietary process, from order entry through tray delivery," Wallace added.

Risk reduction strategies were obtained from interviews with clinical dieticians and dietary directors from Pennsylvania hospitals for their expert opinions.   

"For perspective, the Authority reached out to dietary experts within Pennsylvania's acute care facilities" Wallace said. "The interviews provided a number of risk reduction strategies for hospitals to implement to help reduce the likelihood of a dietary error."

Some risk reduction strategies include: educating all healthcare workers by providing continued education and training about food allergies and special diets as well as the proper way to answer a patient's questions and concerns; creating a written procedure for handling food allergies and special diets for all staff members to follow; food service employees are encouraged to consistently check for two patient identifiers before giving a patient a food tray; and cooks and chefs should use only the ingredients listed on a recipe and should not make substitutions.

The Authority has also 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.

"Consumers can learn from these events as much as healthcare personnel," Wallace added.

The tips also provide a graphic that shows potential vulnerabilities in the dietary process that hospitals can consider to reduce the risk of a dietary error.

"Understanding how the process works will help patients and their caregivers know what questions should be asked so they can help reduce the risk of a dietary error," Wallace said.

Pennsylvania Patient Safety Authority, US, Susan Wallace