EXECUTIVE SUMMARY

Food services can play an important role in patient safety, but may not receive enough attention. Specific policies and procedures should address patient safety.

  • Allergy conflicts are the most common type of dietary errors.
  • Encourage staff to think of dietary errors as patient safety events.
  • Recipe substitutions must be carefully monitored.

Food services is one area in the hospital that can have a profound effect on patient safety, but which does not always get proper attention from efforts to protect patients. Risk managers should assess the policies and procedures of food services and be sure to incorporate this department into all patient safety initiatives.

Dietary errors are a more common and more serious threat to patient safety than many risk managers realize, says Susan C. Wallace, MPH, CPHRM, patient safety analyst with the Pennsylvania Patient Safety Authority (PPSA) in Harrisburg. She recently authored a report for PPSA on food safety risks and found that 285 dietary errors were reported to the PPSA in a five-year period, with eight events causing serious harm to patients. The most common type of error involved meals delivered to patients who were allergic to a food item on the tray. (For more on the report, see the story later in this issue. See the story in this issue for Wallace’s research on another patient safety issue involving newborns.)

When she worked in hospitals as a risk manager, Wallace received event reports regarding dietary events and began to realize that the threat was underestimated.

“There wasn’t much written about this in the literature about this risk, not a lot of studies and advice,” Wallace says. “There is plenty about dietary information for patients, but not much specifically addressing the potential for patient harm and how to prevent that harm.”

Wallace researched the issue with dietary services professionals and found that they were more aware of the issue than the risk management community and developed strategies that should be incorporated into a hospital’s overall patient safety efforts. One of the professionals she consulted was Jennifer Ross, director of nutrition services at Abington (PA) Jefferson Health hospital, who says healthcare organizations are only now recognizing the significance of food services in keeping patients safe. Her department typically prepares up to 400 trays per meal at the hospital.

“Earlier in my career, a few decades ago, there wasn’t an acknowledgment that food service plays a huge role in keeping patients safe in addition to helping patients get better and serving emotional needs also,” Ross says. “We have a huge impact on both safety and the patient experience.”

Staff Play Key Role for Safety

Allergy conflicts are the most common and obvious type of dietary error, but there are other ways a simple tray of food can threaten patient safety, Ross and Wallace note. Patients may be on diet restrictions of one sort or another, diabetic patients may need to choose certain amounts of specific types of foods for each meal, others may be on only a liquid or soft food diet, and many patients will be restricted from any food before surgery.

“The risk is more than theoretical. We have seen cases in which the wrong tray was delivered to a patient with an allergy and they did have a significant allergic reaction,” Wallace says. “These were events that caused harm.”

Frontline staff members play a key role in preventing dietary errors, Wallace says. It may be easy to assume that the biggest threats to patient safety have passed once the meal is prepared and on its way to the patient’s room, but Wallace points out that the staff members delivering a meal face more challenges than one might imagine.

Patients’ dietary restrictions might have changed since the meal was prepared, for instance, or the patient may have been moved to another room or unit. Some hospitals put dietary restrictions on the white board in the patient’s room, along with other common notifications such as fall risk, Wallace says. That allows the dietary service staff member another chance to confirm at the last minute that the tray is appropriate.

Hospitals also use tools such as a wheel posted on the patient’s door that can be changed to denote the patient’s dietary status, or special stickers and wristbands.

“A patient’s meal tray passes through so many hands, from the conception of that meal to cooking and putting the tray together to delivering it to the patient. Every one of those steps is a possible point of error,” she says. “Staff members have to be educated about the importance of dietary services in patient safety, but they also have to be given the time and authority to do their jobs right, to take the time to check double identifiers, and to ask questions if something is not right.”

Encourage Safety Approach to Diet

Risk managers should encourage staff to report dietary errors as adverse events, remembering that not everyone makes that connection automatically. A patient receiving the wrong food tray might just be seen as a simple mistake unless it results in actual harm, but staff should be encouraged to report all dietary errors and near misses, she says. Once staff begin reporting dietary errors routinely, a risk manager may realize that there are more than previously realized, she says.

Patient satisfaction surveys and similar reports from patients can reveal potential patient safety threats, Wallace says, but you sometimes have to dig to find them. Like some staff, patients often do not associate dietary errors with patient safety unless actual harm occurs, so a patient’s report of a dietary error may be buried in other information about the hospital experience, either as a minor complaint or throwaway comment. The patient may report receiving a particular food item he or she was allergic to, but another might casually mention receiving a tray with someone else’s name on it, for instance.

Some allergy errors occur because dietary information is entered into the electronic medical record improperly, Wallace notes.

“The information is in the record, but not where you would expect to look for it,” she says. “They might have put it under medication allergies because they didn’t know where else to put it. You have to have established places in the record to put food allergies so that everyone is working under the same expectations.”

Staff are more likely to overlook or improperly record food allergies for patients admitted through the ED, Wallace says. Emergency patients often are not around long enough for food to be a concern, and procedures in the ED may be different from the standard admissions process, she notes.

“Consistency is important,” Wallace says. “If the emergency department puts a food allergy band on the wrist but doesn’t note the allergy in the same place in the record as everyone else, it can still be overlooked.”

Situational Awareness for Safety

Some states give dieticians the authority to change dietary prescriptions without going to the patient’s doctor first, Wallace notes, which she says can reduce some errors related to delays and misunderstandings.

Ross encourages situational awareness in her department. The first manager on duty each morning in food services begins by completing a checklist called “Create a Safe Day.” The checklist includes the number of days since the department experienced a food safety incident, the midnight hospital census, the day’s eating census, any noteworthy conditions at the hospital, or concerns with the day’s menus. That checklist is posted in the department so anyone can refer to it during the day, and it also is used when Ross or another food service manager participates in the hospital’s daily check-in phone call with 34 representatives from all over the hospital, Ross notes. She listens for any situations that might affect food services or in which her department can affect patient safety.

“An example would be one day when infection control reported that there was an unusually large number of patients on precautions,” she says. “I took that information to my staff because we have to gown and glove like everyone else, and that can be very time-consuming. We told our staff to take this into account and to let us know if they needed help on the floors, because we’re willing to provide that extra help rather than having them feel rushed and pressured, which can affect compliance with precautions.”

The food service department also holds safety huddles twice a day to go over the morning’s checklist, anything learned during the check-in call, and developments during the day, supply needs, or concerns, Ross says. She also identifies any higher-risk patients, such as those with allergies that do not always transfer from the hospital’s database to the computer system used for preparing meals.

During the safety huddle, Ross also asks what is working well in the department, which gives staff members a chance to recognize one another’s good work or to highlight successful problem-solving, and she often reads patients’ comments praising their experiences with the hospital’s food service. Before the huddle ends, Ross asks for any questions or comments from the staff. Information learned from the huddles is added to the day’s safety checklist, posted so that any staff on a later shift during the day can check it. (See the in this issue for more strategies to reduce dietary errors.)

The hospital’s computer system generates a menu specific for each patient, and staff use the two-patient identifier rule throughout the process of preparing meals and right up to the point the tray is given to the patient. Ross cautions that no matter what computer systems a hospital uses, it is still necessary to double-check trays with any updated information that may arrive during the day. Patient menu restrictions can change quickly and significantly after food services obtains the day’s menu requirements, so check the computer system for changes, and also take advantage of any information that may not have been entered into the computer system yet. Encourage nurses to notify food services of any midday changes to a patient’s diet.

“Especially if you’re in a hospital that is less computerized than some, the information you’re working with may be old,” Ross says. “The patient may have turned NPO by the time you assembled that tray. It’s important to work off of some type of update list, whether that comes from the computer system or a nursing station.”

SOURCES

  • Jennifer Ross, Director of Nutrition Services, Abington (PA) Jefferson Health, Telephone: (215) 481-2754. Email: jennifer.ross@jefferson.edu.
  • Susan C. Wallace, MPH, CPHRM, Patient Safety Analyst, Pennsylvania Patient Safety Authority, Harrisburg, PA. Email: patientsafetyauthority@pa.gov.