Delivering the Right Diet to the Right Patient is Complicated as Data Shows in the June Pennsylvania Patient Safety Advisory
Eight events reported with serious harm to patients; Consumer tips available
HARRISBURG, Pa., June 15, 2015 /PRNewswire-USNewswire/ -- Dietary errors occurred in 285 events reported to the Pennsylvania Patient Safety Authority with eight events causing serious harm to patients, according to the June Pennsylvania Patient Safety Advisory article released today.
Analysis of events reported to the Pennsylvania Patient Safety Authority from January 2009 through June 2014 showed meals delivered to patients who were allergic to a food item on the tray were identified as the most frequently reported type of event (n=181). Other types of events included patients receiving the wrong diet (n=50), meals meant for other patients (n=43), and meals delivered to patients who were not to receive any food by mouth (n=11).
"Delivering the right tray of food to the right patient at the right time in the acute care setting is a complicated process," Susan Wallace, MPH, CPHRM, patient safety analyst of the Pennsylvania Patient Safety Authority said. "To get it right, several hospital departments and services must communicate, cooperate and function as a coordinated team.
"As the Authority data shows, a dietary error can occur at any point in the dietary process, from order entry through tray delivery," Wallace added.
Risk reduction strategies were obtained from interviews with clinical dietitians and dietary directors from Pennsylvania hospitals for their expert opinions.
"For perspective, the Authority reached out to dietary experts within Pennsylvania's acute care facilities" Wallace said. "The interviews provided a number of risk reduction strategies for hospitals to implement to help reduce the likelihood of a dietary error."
Some risk reduction strategies include: educating 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; creating a written procedure for handling food allergies and special diets for all staff members to follow; food service employees are encouraged to consistently check for two patient identifiers before giving a patient a food tray; and cooks and chefs should use only the ingredients listed on a recipe and should not make substitutions.
The Authority has also developed consumer tips for patients to become more involved in the process.
"It is important for the patient or caregiver to pay attention to meals provided in the hospital," Wallace said. "The tips provide two narratives from actual events within Pennsylvania healthcare facilities in which the patients have very different outcomes based upon the decisions they make when eating their meal while in the hospital.
"Consumers can learn from these events as much as healthcare personnel," Wallace added.
The tips also provide a graphic that shows potential vulnerabilities in the dietary process that hospitals can consider to reduce the risk of a dietary error.
"Understanding how the process works will help patients and their caregivers know what questions should be asked so they can help reduce the risk of a dietary error," Wallace added.
For more information about dietary errors in Pennsylvania and how to reduce them go to the June Pennsylvania Patient Safety Advisory article, "Delivering the Right Diet to the Right Patient Every Time," at www.patientsafetyauthority.org. Consumer tips can also be found at the Authority's website by clicking "Patients and Consumers" on the left hand side.
Other highlights of the 2015 June Advisory include the following:
- Aligning Behavioral Health Management of Patient Aggression with State and National Initiatives: Operationalizing organizational changes to affect noncoercive patient care strategies requires a long-term commitment that starts with leadership. Many behavioral health facilities in Pennsylvania have aligned their approaches to noncoercive management of patient aggression with state and national initiatives, and analysts discuss two facilities' strategies in particular.
- Oral Anticoagulants: A Review of Common Errors and Risk Reduction Strategies: Pennsylvania healthcare facilities submitted 831 medication error reports associated with the oral anticoagulants warfarin, apixaban, rivaroxaban, and dabigatran to the Authority from July 2013 through June 2014. The most commonly reported errors were drug omissions (32.5%), "other" errors (18.5%), and extra doses (11.7%).
- Antibiotic Stewardship in Hospitals and Long-Term Care Facilities: Building an Effective Program: Inappropriate antibiotic use perpetuates and exacerbates antibiotic resistance. Antibiotic stewardship programs help to ensure optimal treatment for patients with infections and may enhance the length of time antibiotics in current use remain effective. Authority surveys of hospitals and long-term care facilities demonstrate opportunities for improvement in all facets of antibiotic stewardship.
To view the complete 2015 June Pennsylvania Patient Safety Advisory, go to www.patientsafetyauthority.org.
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SOURCE Pennsylvania Patient Safety Authority
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