The Pennsylvania Patient Safety Authority has issued a new report highlighting the potential hazards and problems with food service in hospitals. The report found that mix ups and mistakes were more common than you might think.

Patients with special dietary needs, which would include allergies, were found to be getting the wrong food or food potentially contaminated with allergens quite often, according to the report. The PPSA found 285 mistakes that resulted in problems with eight of those being life-threatening.

All eight of the life-threatening instances were with patients who had a food allergy.

Of the 285 events reported, 181 of them were allergy-related. So with more than half of the incidents involving food allergy, it’s not surprising that the most serious were also food allergies. The rest of the events were mis-labeled trays or other issues that caused food to be delivered to the wrong patient – perhaps a fasting patient before surgery getting the tray meant for the next room or a diabetic patient getting a non-diabetic tray.

The report highlights several serious mistakes.

Lead author Susan Wallace of the PPSA described some of the worst mistakes. A patient allergic to shellfish was given fish and required intravenous medications and intensive care. That mix up involved a mis-labeled tray.

Another patient was allergic to pineapple and given a fruit cup containing it. The allergen was listed under allergies to drugs, not food, on the patient’s chart.

Wallace recommends continued education on food allergies and other dietary issues for hospital staff. Some hospitals have adopted creative means of labeling food and patients’ rooms using color charts, “food wheels,” and so forth.

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