Most dietary errors are related to food allergies, according to an analysis of errors reported to the Pennsylvania Patient Safety Authority over five years.

A total of 285 dietary errors were reported to the PPSA from January 2009 through June 2014, and 181 involved meals delivered to patients who were allergic to a food item on the tray. Other types of events included 50 patients receiving the wrong diet, 43 receiving meals meant for other patients, and 11 meals delivered to patients who were not to receive any food by mouth.

Delivering the right tray of food to the right patient at the right time is a complicated process that requires coordination among several departments, notes PPSA analyst Susan C. Wallace, MPH, CPHRM.

Wallace gathered risk-reduction strategies from dietary services professionals. The following are some of the suggested strategies:

  • Educate all healthcare workers by providing continued education and training about food allergies and special diets, as well as the proper way to answer a patient’s questions and concerns.
  • Create a written procedure for handling food allergies and special diets for all staff members to follow.
  • Encourage food service employees to consistently check for two patient identifiers before giving a patient a food tray.
  • Require that cooks and chefs use only the ingredients listed on a recipe and not make substitutions.

The full PPSA report is available online at: