The little-noticed problem of hospital food mix-ups can do real harm to patients, according to a new study released by the Pennsylvania Patient Safety Authority (PPSA).
The study examined adverse events reported to PPSA and found that hospital staff committed 285 food-related errors between January 2009 and June 2014, Stacey Burling writes for the Philadelphia Inquirer.
Overall, 181 of the events were allergy-related errors—including eight that resulted in serious harm to patients. For instance, hospital staff gave fish to a patient with a seafood allergy, who then had to be injected with epinephrine, given several intravenous drugs, and moved to the ICU for observation.
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Other types of errors included serving meals to patients when they were supposed to be fasting and giving patients the wrong food for their diet. In one case, hospital staff incorrectly noted a fruit allergy in the section for drug allergies. In another, staff charted a seafood allergy as a "seawater" allergy.
The study found that the errors occurred at various points in the dietary process, from entering food orders to delivering trays to patients.
Susan Wallace, an analyst with ECRI Institute who authored the report for PPSA, says the food-safety data were important to share because hospitals general do not have a good sense of incidents at other facilities.
"What I want to do is educate the hospitals and say, 'Hey, look what's going on,'" she explains.
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Wallace says eliminating errors requires good coordination between providers and other staff. Problems often arise, she says, when food service workers do not see a patient's entire electronic health record or when hospital staff do not know where to look in the record for allergy information.
PPSA outlined several risk-reduction strategies for providers, including:
- Requiring cooks to only use ingredients listed in recipes, without making any substitutions;
- Continuously educating all hospital staff on allergies, special diets, and how to address patients' concerns;
- Creating a standard written procedure for all staff on addressing patient allergies and diets; and
- Encouraging food service employees to check for two identifiers of patients before giving them food trays (Burling, Philadelphia Inquirer, 6/28; PPSA release, 6/15).
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