Pennsylvania Patient Safety Authority analysts identified 285 events involving dietary errors submitted January 2009 through June 2014. Meals delivered to patients who were allergic to a food item on the tray were identified as the most frequently reported type of event (n = 181), with serious harm reported in eight events. Other types of events included patients receiving the wrong diet (n = 50), meals meant for other patients (n = 43), and meals delivered to patients who were not to receive any food by mouth (e.g., preoperative patients) (n = 11). Review of the published literature and interviews conducted by analysts of clinical dietitians and dietary directors in Pennsylvania hospitals suggests strategies to prevent dietary errors and patient harm by standardizing practices, such as matching food allergies with dietary ingredients, and by using communication tools, such as whiteboards or diet wheels.
Delivering the right diet to the right patient at the right time is a carefully orchestrated team effort in the acute care setting.1 The medical staff prescribe the diet, and the nursing and dietary staff ensure that patients receive meals that are tailored to specific health conditions and designed to support continued recovery and health. During routine review of Pennsylvania Patient Safety Reporting System (PA-PSRS) reports, analysts noted several events involving patients who received incorrect diets, resulting in harm.
Published information identified from a literature search indicated that food allergies are a large and growing public health problem in the United States.2 Studies have estimated that the prevalence of food allergies in the US adult population may be nearly 4%.2 Analysis of PA-PSRS data revealed the types of foods reported by patients with allergies and how this compares with food allergen prevalence in the United States.
Other information reported in the literature and interviews conducted by analysts of dietary personnel in Pennsylvania hospitals suggests strategies to prevent dietary errors and patient harm by standardizing practices, such as matching food allergies with dietary ingredients, and by using communication tools, such as whiteboards or diet wheels.
Analysts queried the PA-PSRS database for reports submitted January 2009 through June 2014 of events involving patients who had experienced a dietary error related to oral feedings. Terms such as “allergy,” “tray,” “wrong,” “NPO” (nothing by mouth), and “diet” were used to identify reports, which were then analyzed individually to identify only those reports that described dietary events. Analysts determined the reason for the dietary error by reviewing the event report narratives and categorized the events into one of four predominant classifications: allergy to a food item on the tray, receiving the wrong diet, meals meant for other patients, and meals delivered to patients who were not to receive any food by mouth. Event reports were analyzed according to event type and harm score.
Narratives from event reports involving food allergies were also reviewed to identify the types of foods involved in allergic reactions and to compare these foods with the eight major food allergens in the United States—milk, egg, peanuts, tree nuts, soy, wheat, fish, and crustacean shellfish.1
Analysts conducted a review of the literature, as well as an Internet search, to identify allergy statistics, best practices, and risk reduction strategies for dietary issues in healthcare facilities. Interviews with clinical dietitians and dietary directors were also conducted to identify best practices and resources developed specifically for dietary departments to reduce the risk of patient harm in healthcare facilities.
Analysts identified 285 dietary events submitted through PA-PSRS. The majority of dietary events (n = 181, 63.5%) involved patients who received a tray containing a food item to which the patient was allergic; more than three-quarters of these allergies (n = 141, 77.9%) were both known and documented in the medical record prior to the event (see Figure 1). In 8 (4.4%) of the 181 events in which patients with a known food allergy ingested the identified food, serious harm occurred, resulting in emergency administration of epinephrine or other medications, transfer to a higher level of care, and/or intubation. Figure 1. Allergy-Related Dietary Events Submitted to the
Pennsylvania Patient Safety Authority January 2009
through June 2014 (N = 181)
Other dietary events involved patients receiving the wrong diet (n = 50 of 285, 17.5%), patients receiving a tray meant for another patient (n = 43 of 285, 15.1%), and patients who were supposed to have a status of NPO who received a food tray (n = 11 of 285, 3.9%).
Types of Dietary Events
The following are examples of events reported to the Pennsylvania Patient Safety Authority involving dietary allergy errors without injury:*
The nurse ordered apple juice for patient, not realizing that the patient was allergic to apples. After discovering error, nurse then called dietary to inform them of patient’s allergy to both apples and carrots. When patient’s meal arrived, tray contained a dish of carrots and carrots in the salad. After talking to the patient, the nurse learned the patient had received apple juice and applesauce the prior day.
Patient has documented allergy to seafood. Was given a house tray for lunch, which had main course of fish. Personal caregiver brought issue to nursing’s attention. The caregiver states patient “only had one bite” of food. Upon review of chart, allergy to “sea water” was documented under “medication,” with comment saying patient has allergy to seafood, not sea water. Kitchen informed of allergy. Allergy information changed in computer. Tray was discarded and new tray was ordered. No allergic reactions noted.
The patient’s breakfast tray had a packet of peanut butter on it. Patient was alert, did not touch the peanut butter. Patient has a history of severe allergic reaction to peanut butter and beans. Documented under allergies, and dietary made aware.
* The details of the PA-PSRS event narratives in this article have been modified to preserve confidentiality.
Examples of allergy events with injury are as follows:
The patient entered via emergency department. Allergy to seafood documented in [emergency department] record. Patient was admitted to [unit], seafood allergy not documented in [electronic medical] record. Patient received fish on food tray during admission and suffered anaphylactic reaction requiring multiple IV [intravenous] medications, IM [intramuscular] epinephrine, and [intensive care] observation. The patient’s condition improved and returned back to baseline. No residual effects. Seafood allergy was updated in [electronic medical record], and allergy band placed on patient’s wrist. Both nurse and physician were reeducated and counseled regarding completion of the nursing assessment, as well as confirming patient’s allergies and entering them in the patient’s electronic record.
The patient received a fruit cup on food tray that contained pineapples. The patient is allergic to pineapples. This was documented in the electronic medical record; however, it was noted as a drug not food. So the pineapple allergy was not transferred to the [dietary] department. The patient did eat the fruit except for the pineapple. The patient experienced an allergic reaction requiring intubation and transfer to the critical care unit. The patient was extubated and has since been discharged.
Patient [is] allergic to fish. Allergy listed during admission only as drug allergy but not food allergy. Patient slightly less alert related to treatment and did not realize he was eating fish received on dinner tray. Patient with immediate allergic response to fish was given medication and transferred to ICU [intensive care unit] for upper airway edema and required intubation.
Examples of patients who received a different diet than was ordered, such as a diabetic, low-salt, or thickened diet, are as follows:
The patient is on a pureed-thin liquid diet. Received a regular tray and ate the meal when it is to be pureed. Meal consisted of chicken, cornbread, and fruit cup.
The patient was given [food supplement A] with her lunch–[food supplement B] had been ordered. Patient’s blood sugar was 354 [that night]. Food services apparently placed wrong supplement on meal tray.
The patient received wrong diet on lunch tray. Patient is ordered a dysphagia diet [for patients with difficulty swallowing] with nectar-thick liquids and received a whole chicken breast and a piece of white bread on tray.
Examples of patients who received a tray meant for another patient are as follows:
[Dietary] hostess gave patient wrong food tray with another patient’s name on it. The food order was correct in the computer system and labeled correctly but given to the wrong patient. Physician notified. No harm to patient.
Patient on clear liquids due to acute GI [gastrointestinal] bleed. Given dinner tray of another patient who was on a cardiac 2 gm sodium diet. Patient and family stated no one asked [the patient’s] name. Patient ate some of the food from the wrong dinner tray.
Patient’s diet is listed in computer orders as gluten-free (patient has gluten allergy); however, patient’s lunch tray [dietary slip] listed diet as regular house diet. Dietary contacted immediately to inform and correct. There are two patients on unit with the same last name, and the other patient received the gluten-free diet instead. Patient consumed entirety of lunch tray contents, which did include items containing gluten. Attending physician informed, and nutritionist in to see patient regarding the event.
Examples of patients who received trays despite NPO orders are as follows:
Staff put verbal order for soft diet on wrong patient chart for patient who was to be NPO. Patient was given a soft diet. Patient aware [of NPO status] and informed the dietician. Nurse manager made aware of event and will discuss with staff that took verbal order.
Patient came in with PEG [percutaneous endoscopic gastrostomy] tube. As per transfer record, patient was on NPO and tube feed. Dietary staff came up and brought a tray. The order was put in wrong and was clarified right away by the attending doctor.
Patient ordered NPO. Written on whiteboard in patient’s room. Dietary gave patient breakfast tray and patient ate wrong patient’s tray.
Types of Food Allergies
Foods most commonly reported to the Authority as food allergens were very similar to the eight major food allergens that account for 90% of all food-related allergic reactions in the United States.2,3 Fruit, dairy, egg, and fish were the most frequently reported food allergens; and 10 major food allergens accounted for nearly 90% of the food-related allergic reactions in dietary events reported in Pennsylvania hospitals (see Figure 2).
Figure 2. Foods Reported as Allergens in Events Submitted
to the Pennsylvania Patient Safety Authority
January 2009 through June 2014 (N = 199)
Healthcare facility workers are challenged with meeting the dietary needs of their patients. From the moment a patient arrives in the facility until the patient leaves, medical staff, nursing, and dietary workers coordinate efforts for patients with specific dietary needs caused by food allergies, medical conditions such as diabetes or dysphagia, and food interactions with medications such as anticoagulants.1
Patients’ dietary needs may not remain static throughout their hospitalization. As a result of medical status changes, patients may be transferred from a medical-surgical unit to a specialized unit (such as intensive care), prepped for a surgical procedure (including an NPO order), or moved within a unit because of a change in behavior. Transfers, treatments, and tests may necessitate changes to a patient’s diet order or may change the location of the patient at any time of the day, which may result in the patient receiving the wrong diet or tray.1 Errors may occur at many points in this multi-step workflow; see “How a Diet Error Can Occur” for more information.
Limited guidance has been published to aid healthcare institutions in the reduction of dietary errors. Most literary resources focus primarily on food allergy prevalence and reactions in the pediatric and adult populations,2 best practices to improve patient satisfaction,4 use of computer software that aids in nutrition care management,5 and strategies to improve food service quality.6
One hospital developed guidelines based on the “service delivery innovation profile” featured on the Agency for Healthcare Research and Quality website.7 After experiencing many events of the wrong food being delivered and often consumed by patients on a 58-bed medical-surgical floor, a Tennessee hospital developed a “diet wheel” tool to decrease the number of dietary errors. The diet wheel was hung on the patient’s door and allowed the nursing staff to “dial” to the type of diet ordered for the patient (e.g., renal, full liquid, low fat, low sodium, NPO), providing a visual cue for the dietary staff when delivering a food tray to the patient’s room.
After using the diet wheel for a period of time, nurses reported they rarely observed instances in which a patient consumed a different diet than that ordered by the physician, and there were fewer interruptions of nurses to clarify a diet order. Nursing staff expressed satisfaction with the results of the program.7
Other visual cues used by hospitals include patient whiteboards that serve as a communication tool among hospital providers and as a mechanism to encourage patient and family engagement,8 as well as stickers on medical records and color-coded allergy wristbands that alert medical staff of the patient allergy or specialized diet.9
Previous work by the Authority has discussed the value of standardizing the colors and meanings of wristbands, as well as providing
information and resources about best practices.
Caution may be warranted if food and medical allergies are documented in different parts of an electronic or written health record. Interfaces between dietary documentation and the medical documentation may be helpful.
Guidelines from regulating and accreditation entities.
Governmental and nongovernmental accrediting organizations and regulatory bodies such as the Pennsylvania Department of Health,10 the Joint Commission,11 and the Centers for Medicare and Medicaid Services (CMS)12 offer guiding principles for dietetic services in their regulations and interpretative guidelines for hospitals.
Information typically includes general guidance for organization and staffing, equipment, food storage, education programs, infection control, and nutritional aspects of patient care. The guidelines do not specifically address how to ensure the right diet or tray is delivered to the right patient. The Pennsylvania Department of Health states that “conferences should be held regularly within the dietary services department at all levels of responsibility, to disseminate information, interpret policy, solve problems, and develop procedures and program plans.”10
The Joint Commission does not have a separate chapter on dietary guidance; rather, it recommends dietary compliance in their chapters on leadership, provisions of care, and record of care.11 For example, in the chapter on record of care, provisions call for the medical record to contain any allergies to food.
CMS calls for a system for diet ordering and patient tray delivery.12 Other provisions call for menus to meet the special needs of the patients, screening criteria to identify patients at nutritional risk, review of patient records to verify the diet orders are provided as prescribed, and review of competencies for administrative and technical personnel in their assigned duties. A 2014 CMS ruling allows qualified dietitians or nutritional professionals to order a patient diet. See “CMS Rules on Therapeutic Diet Orders” for information about diet orders in Pennsylvania.
Food allergy is a growing public health concern in the United States. Between 1997 and 2011, there was a reported 50% increase in allergies among children.1-3 As many as 15 million people have food allergies—9 million adults (i.e., 4% of all adults) and 6 million children (i.e., 8% of all children), with a greater prevalence in younger children. Food allergies appear to be more common in boys than in girls.1-3
The Centers for Disease Control and Prevention reported that food allergies result in more than 300,000 ambulatory care visits a year among children under the age of 18. Most allergic reactions result from foods that were thought to be safe. Some allergic reactions can be attributed to a product mislabeling or cross-contact during food preparation.1-3
Following ingestion of a food allergen, a person with food allergies can experience a range of reactions, including a severe, life-threatening allergic reaction called anaphylaxis. Symptoms of allergic reactions can include tingling or itchy sensations; external edema; flushed skin, rash, or hives; abdominal cramps, emesis, or diarrhea; and coughing, stridor, or wheezing. Anaphylaxis may progress to bronchospasm, hypotension, upper airway obstruction, shock, cardiac arrest, or death.1-3 Healthcare providers may be less familiar with the gastrointestinal manifestations of anaphylaxis, such as emesis or diarrhea, which may precede hypotension and shock, as compared with respiratory manifestations.13
Depending on the severity of the allergic reaction, treatments can range from the use of antihistamines or injection of epinephrine or other medications to transfer to a higher level of care or intubation. Strict avoidance of the allergy-causing food is the only way to avoid a reaction. Eating away from home can pose a significant risk to people affected by food allergies, as close to half of fatal food allergy reactions are triggered by food consumed outside the home.1-3
Reading ingredient labels is a primary method to avoid allergens. Since hospitalized patients do not have this opportunity, they are dependent on healthcare workers to identify and inform the appropriate network of individuals about their food allergies and to provide safe food choices.1-3
Risk Reduction Strategies
In the absence of abundant literature and clinical guidelines specific to reducing dietary events in the acute care setting, the Authority reached out to clinical dietitians and dietary directors in Pennsylvania hospitals for their expert opinions.14-18
In a conversation with the Authority, Jennifer Ross, director of nutrition services, Abington Health, highlighted several strategies to make sure patients are not served foods to which they have a known allergy.18 She said Abington Health compares information about a patient’s allergies with food ingredient information.
Using a food service interface integrated with the main hospital’s electronic health system, dietary orders are automatically updated in real time with patient allergies, admission and discharge information, and transfers. Not all food allergies are entered into the interface, she said, and some must be entered manually. Any allergy that is not addressed using the interface is posted on a report and reviewed at safety meetings twice a day.
All menus and tray tickets for patients with allergies are marked with a prominent red slash, Ross said. “This tells each staff member to use the safety tool STAR so they can stop, think, act, and review,” she said. “Trays with these slashes also require an independent second check and sign-off, usually done by a manager or supervisor. It must be someone who has not participated in assembling the tray in order to get fresh eyes.”
The following strategies are suggested for healthcare facilities seeking to improve the quality of dietary care for patients.
Education is the first line of defense. Provide continuing education and training about food allergies and special diets, as well as the proper way to answer patients’ questions and concerns, to all staff, including healthcare providers (such as nurses and dietitians) and allied health professionals (such as food service personnel).1,14-18
Create a written procedure for handling food allergies and special diets for all staff members to follow.1-3 Consider the following questions when creating a policy:1
Who will be responsible for identifying the allergic patient’s dietary needs or special diets?
How will dietary information be disseminated to the rest of the medical staff, to the food service staff, and to the patients’ visitors?
What is the hospital’s policy to address the questions of the patient who has a food allergy or other dietary restriction?
When would a patient be referred to a dietitian to address the patient’s food allergies or special diets?
What does the food service staff need to know to avoid cross-contact with allergen-containing foods?
- Develop a staff team of physicians, nurses, dietitians, food service personnel, and unit secretaries to coordinate the continuum of processes that impact patients with food allergies or other dietary needs.1
- Examine a sample of medical records to review where personnel are recording patients’ food allergies. Consider listing all allergies (e.g., medication, food, latex) in the same place.1
- Use communication tools such as diet wheels, whiteboards, stickers for the menu or medical record, or informational wristbands.7-9
- Eliminate foods from the hospital that are known to cause interactions with certain medications, such as grapefruit or cranberry juice.1
- Make sure tray servers consistently check at least two patient identifiers (such as patient name and date of birth).14-18
- Ensure cooks/chefs use only the ingredients listed on a recipe and do not make substitutions.16
- Place the patient’s diet information on the tray to alert kitchen staff assembling or checking the meal tray that the patient has a food allergy or has a special diet. Staff can then remove the restricted food item before the tray leaves the kitchen.18
- Meet in a huddle daily or more often to review the daily census, food substitutions, and other circumstances that could affect the daily operations of the department.18, 19 Include kitchen staff, registered dietitian nutritionists, retail staff (workers who are generally not involved with patient care), and the management team. See “Dietary Safety Huddles” for an example of a dietary safety huddle agenda.
- Provide nutrition consultation, and consider the following when meeting with a patient with a food allergy or special diet:1
- Be understanding, listen carefully, and answer questions thoughtfully.
- Determine if further patient education is needed, and arrange for follow-up.
- Listen carefully to food service complaints. Stay focused on getting all the facts and follow up, as appropriate.1 Review patient satisfaction surveys for patient safety concerns.4
- Interface the food service department dietary orders with the main hospital’s electronic health system so that dietary orders can be automatically updated in real time with patient allergies, admission and discharge information, and transfer information. This also reduces the number of personnel who must manually process the dietary order.5
- Review how a wrong tray or diet was delivered to a patient, and consider steps to prevent this from happening again.1
Delivering the right diet to the right patient at the right time is a complicated process in the acute care setting; multiple hospital departments and services must communicate, cooperate, and function as a coordinated team. A dietary error can occur at any point in the dietary process, from order entry through tray delivery. The most frequent type of dietary event reported through PA-PSRS submitted from January 2009 through June 2014 involved providing a patient a tray that contained a food item to which that patient was allergic; eight of these events resulted in serious harm. As food allergies are a growing public health problem in the United States, hospitals may need to create a safe haven for patients with food allergies.
- Food Allergy and Anaphylaxis Network. Food allergy training guide for hospital and food service staff [online]. 2006 [cited 2015 Mar 4].
- Food Allergy Research & Education. Food allergy facts and statistics for the U.S. [online]. [cited 2015 Mar 4].
- US Food and Drug Administration. Food allergies: what you need to know [online]. 2010 Jun [cited 2015 Mar 4].
- Massachusetts General Hospital. Results of the patient satisfaction survey over the last four years [online]. [cited 2015 Mar 8].
- CBORD Group, Inc. Foodservice Suite [online]. [cited 2015 Mar 8].
- Kim K, Kim M, Lee KE. Assessment of foodservice quality and identification of improvement strategies using hospital foodservice quality model.
Nutr Res Pract 2010 Apr;4(2):163-172.
- Agency for Healthcare Research and Quality. Hospital posts appropriate diet for patient on room door, reducing diet-related mistakes and nursing interruptions [online]. [cited 2015 Mar 4].
- Sehgal NL, Green A, Vidyarthi AR, et al. Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations.
J Hosp Med 2010 Apr;5(4):234-9.
- Use of color-coded patient wristbands creates unnecessary risk. PA PSRS Patient Saf Advis [online] 2005 Dec 2 [cited 2015 Mar 4].
- 28 Pa. Code §§ 111.1-111.27. Also available at
- Joint Commission. Joint Commission E-dition [online]. [cited 2015 Mar 6].
- Centers for Medicare and Medicaid Services (CMS). Appendix A—survey protocol, regulations and interpretive guidelines for hospitals [online]. In: CMS. State operations manual. 2015 Apr 1 [cited 2015 Apr 1].
- Kim H, Fischer D. Anaphylaxis.
Allergy Asthma Clin Immunol 2011 Nov 10;7 Suppl 1;S6.
- Werner, Annette (Clinical Nutrition Manager, Doylestown Hospital); Strogis, Ellen (Patient Service Manager, Doylestown Hospital). Conversation with: Pennsylvania Patient Safety Authority. 2014 Aug 8.
- Ignatz, Colleen (Clinical Nutrition Team Leader, Jefferson Hospital); Hampton, Kristen (Director of Nutrition Services, Jefferson Hospital). Conversation with: Pennsylvania Patient Safety Authority. 2014 Oct 30.
- Kipe, Margaret (Director, Nutrition Services, Reading Health System). Conversation with: Pennsylvania Patient Safety Authority. 2015 Feb 12.
- Shepps, Amy (Clinical Nutrition Manager, Pinnacle Health System). Conversation with: Pennsylvania Patient Safety Authority. 2015 Feb 18.
- Ross, Jennifer (Director of Nutrition Services, Abington Health). Conversation with: Pennsylvania Patient Safety Authority. 2014 Oct 30.
- Ross, Jennifer (Director of Nutrition Services, Abington Health). E-mail to: Pennsylvania Patient Safety Authority. 2015 Apr 4.
How a Diet Error Can Occur
CMS Rules on Therapeutic Diet Orders
The Centers for Medicare and Medicaid Services (CMS) announced a rule in 2014 regarding hospital diet orders, stating that patient diets must be ordered by a practitioner responsible for the care of the patient or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with state law governing dietitians and nutrition professionals.1
Pennsylvania is 1 of 16 states that has significant statutory or regulatory impediments that presently preclude registered dietitian nutritionists (RDNs) from ordering patient diets, according to Meg Rowe, MS, RD, LDN, FAND, consumer protection and licensure chair, Pennsylvania Academy of Nutrition and Dietetics.2
Allowing registered dietitians the ability to order patient diets would create efficient and effective practices for RDNs to perform at the height of their competencies, according to Rowe. The provision of nutrition care to patients would be streamlined, resulting in more timely nutrition intervention for the patients and, ultimately, improvement of patient care and safety, she said.
To be implemented in Pennsylvania, the rule needs approval by the Pennsylvania Department of Health and the Pennsylvania State Board of Nursing, and then each hospital and its medical staff must approve privileges for qualified dietitians and nutrition professionals to order diets. Rowe and the CMS task force of the Pennsylvania Academy of Nutrition and Dietetics are working with professional groups such as the Hospital and Healthsystem Association of Pennsylvania, the Pennsylvania State Board of Nursing, the Pennsylvania Osteopathic Medical Association, and the Pennsylvania Medical Society to obtain privileges for RDNs to be able to order patient diets independently, consistent with the CMS recommendation.1,2
Rowe, Meg (Consumer Protection and Licensure Chair, PA Academy of Nutrition and Dietetics). Conversation with: Pennsylvania Patient Safety Authority. 2015 Mar 5.
Dietary Safety Huddles
A typical agenda at Abington Health includes discussion of the following:
Number of days since the hospital’s last serious safety event
Eating census for next meal
Staffing (e.g., absentees, training, changes to workflows)
Equipment and supplies (e.g., equipment repairs, supplies on order)
Food shortages or substitutions
What’s working well (e.g., staff share a good-patient experience; staff appreciate a coworker who went above and beyond)
Patients with food allergies who are at “high risk” or any patients with special needs or attention
Patient satisfaction reports and comments
Hospital-wide daily check-in (anything of particular note is communicated)
Rewarding “good catches” when staff prevent a patient from receiving the wrong diet order
Other announcements or questions
Source: Ross, Jennifer (Director of Nutrition Services, Abington Health). E-mail to: Pennsylvania Patient Safety Authority. 2015 Apr 4.