Pennsylvania Patient Safety Authority analysts identified 285 events involving dietary errors submitted January 2009 through June 2014. 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), with serious harm reported in eight events. 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 (e.g., preoperative patients) (n = 11). Review of the published literature and interviews conducted by analysts of clinical dietitians and dietary directors in Pennsylvania hospitals suggests strategies to prevent dietary errors and patient harm by standardizing practices, such as matching food allergies with dietary ingredients, and by using communication tools, such as whiteboards or diet wheels.
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