Reducing High-risk Meal Tray Delivery Errors in Inpatient Rehabilitation Through Wristband Scanning and...

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Clinical Nutrition

Background:

• Wrong meal tray deliveries in hospitals endanger patients, especially those with dietary restrictions.
• High-risk errors impact patients with dysphagia, allergies, or feeding assistance needs.

Purpose of the Study:

• To implement a quality improvement intervention to decrease wrong meal tray deliveries.
• To reduce high-risk dietary errors in an inpatient rehabilitation setting.

Main Methods:

• A pre-postintervention study analyzed event reporting data (May 2023-Feb 2025).
• Interventions included wristband scanning, improved handoff forms, dedicated meal carts, communication protocols, and International Dysphagia Diet Standardization Initiative (IDDSI) education.
• Errors were categorized by clinical severity: high-risk, wrong-patient/tray, and administrative.

Main Results:

• Overall meal tray error rates significantly decreased postintervention (1.83 to 0.65 per 1000 patient-days; P=0.025).
• High-risk errors, including allergen exposure and aspiration risks, reduced by over 80%.

Conclusions:

• Targeted, systems-based interventions effectively reduce high-risk dietary errors in hospitals.
• Sustained improvement requires ongoing auditing, feedback, and education.