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 the most frequently reported type of event (181), with serious harm reported in eight events. More than three-quarters of these allergies (77.9%) were both known and documented in the medical record prior to the event. In the eight events where the patient with a known food allergy ingested the identified food, serious harm occurred, resulting in emergency administration of epinephrine or other medications, transfer to higher level of care and/or intubation. Other types of events included patients receiving the wrong diet (50), meals meant for other patients (43), and meals delivered to patients who were not to receive any food by mouth (11).
What You Can Do as a Patient to Help Prevent a Diet Error
While you are a patient in the hospital, there are several people involved who help to ensure you are receiving the correct food for your meals. Someone must take your order, prepare your meal and deliver it to you. If you have a food allergy, those responsible for documenting your allergy, taking your order, preparing your meal and delivering your meal must be especially careful. Because there are so many people involved, mistakes can occur. Below are some tips for you to help make sure you receive the correct food tray while in the hospital:
Real-life Events in Pennsylvania Hospitals - What Would You Do If You Were the Patient?
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 a critical care unit. The patient was extubated and has since been discharged.
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. ocumented under allergies, and dietary made aware.
How a Diet Error Can Occur—Know the Process
Below is a snapshot of how a diet error can occur in a hospital. As you can see, each stage of the process must be done correctly in order for a patient to receive the correct meal. Review the process to make yourself or a loved one more aware of how you can help prevent a diet error while in the hospital.
For more information on preventing dietary errors, go to the 2015 June Pennsylvania Patient Safety Advisory article “Delivering the Right Diet to the Right Patient Every Time” at the Authority’s website at www.patientsafetyauthority.org.