Healthcare News & Insights

Hidden patient safety threat: Dietary errors

Hospital staff may tend to think of avoiding medication errors, infections or surgical complications when addressing patient safety. But there’s another element to patient safety that often goes overlooked: Food allergies and dietary errors. 

Nurse Serving Senior Patient Meal In Hospital Bed

New research from the Pennsylvania Patient Safety Authority shows just how important it is to meticulously check whether patients have any issues with eating certain foods – and whether the meals they’re served in the hospital meet their needs.

Common dietary errors

Food allergies are on the rise. While they’re more common in children, an estimated 4% of adults have a food allergy that would cause them significant harm.

While reviewing existing patient safety data, researchers went a little further to try and see just how many times patients were being placed in harm’s way because of an error with their food.

Looking through Pennsylvania’s Patient Safety Reporting System (PA-PSRS), they singled out medical records where patients experienced a diet-related error.

Researchers classified the errors into one of four categories:

  1. allergy to a food item on the tray
  2. receiving the wrong diet (e.g., not being served low-sodium or gluten-free meals)
  3. meals meant for other patients, and
  4. receiving a meal when medical orders say the patient shouldn’t get food by mouth.

Most dietary errors fell into the first category – almost 64% of those examined. And in all these situations, over 75% of the allergies were already documented in the patient’s medical record.

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, thankfully, most of these errors didn’t affect the patient’s recovery, a small percentage (a little over 4%) of patients experienced serious harm, meaning they needed intubation, emergency administration of epinephrine or another medication, or transfer to a higher level of care.

Hospitals’ performance in the other three categories of dietary errors was better, but still concerning.

Patients received the wrong diet over 17% of the time. Patients received food meant for another patient 15% of the time, and patients who weren’t supposed to receive any food by mouth were given a food tray almost 4% of the time.

Prevention for hospitals

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

Hospitals can try several tactics to reduce the chance of these errors. One hospital in Tennessee came up with a “diet wheel” that was placed on the door of each patient room.

Nurses could set the dial on the wheel to the type of diet ordered for the patient. That made it easier for dietary staff to double-check whether they were delivering the correct food to each patient.

Using the diet wheel not only reduced errors, it also freed up nurses’ time since they weren’t constantly answering questions from dietary staff about patients’ food restrictions.

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

Above all, staff must be regularly trained on the importance of making sure the right food is given to the right patient. It’s helpful to have a written policy in place regarding the hospital’s protocol for identifying food allergies and keeping patients safe from reactions. Be sure to review it with staff on a regular basis.

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