June 2015
Patient in the Hospital? Know What You Are Eating During Your Stay
Allergy and Immunology


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:  

  • Make sure you or a caregiver lets everyone (doctors, nurses, other medical attendants) know if you have a
    food allergy. Errors can occur if the patient does not or cannot give an accurate medical history.
  • Know who will be taking your food order and who will be delivering it.
  • Make sure the person taking your food order and the person delivering the food order confirms who you are by using two types of  patient identifiers (e.g., asks your full name and birthdate).
  • If you receive a food tray before being asked what it is you would like to eat, make sure you let the person know you did not order the food he/she is delivering. This is especially important if you have a food allergy.
  • If you notice something on your food tray that you did not order, or that you know you are allergic to, do not eat it. Let someone know right away if you receive a food tray that you did not order.
  • Do not be afraid to ask questions or tell someone you did not receive the right food tray. If something does not seem right, let someone know right away.
  • While you are in the hospital, follow the same diet guidelines as prescribed by your doctor at home. If hot dogs are not good for you at home, they’re not good for you in the hospital either.
Real-life Events in Pennsylvania Hospitals - What Would You Do If You Were the Patient?
Event #1

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.

Event #2

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

©2018 Pennsylvania Patient Safety Authority