The most common meal mix-up in an acute-care facility is including an item on a tray that triggers a patient’s food allergy, according to a new study of problems created by mismatching food and the patient receiving it.
The other most common mishaps, in descending order, are disregarding a patient’s special diet, giving a patient another patient’s tray and providing meals to patients who are not to have any food by mouth.
“Delivering the right tray or food to the right patient at the right time in the acute care setting is a complicated process,” commented Susan Wallace, patient safety analyst for the Pennsylvania Patient Safety Authority, a watchdog government agency. “To get it right, several hospital departments and services must communicate, cooperate and function as a coordinated team.”
Still, the incidence of mix-ups is relatively rare, judging from the study. From January 2009 through June 2014, only 285 dietary errors were reported to the authority.
The bulk, or 181 incidents, involved the inadvertent inclusion of allergens on an allergic patient’s tray. The information released by the authority did not say whether or not the patient had alerted the foodservice department that he or she had an allergy.
A patient being served food from a different diet was reported in 50 occasions, and the wrong meal was delivered to the wrong patient 43 times.