Manage Abstracts

Providing appropriate nutrition in hospitals and long-term care (LTC) facilities is an essential component of patient care; errors could cause potential harm. The Patient Safety Learning System (PSLS) is a web-based tool for healthcare professionals to report critical and non-critical patient safety events. There is limited research conducted on food service errors in the hospital setting.

To determine the prevalence of critical food service related errors reported to PSLS, and to identify patterns in types of critical error (texture, allergy, safety), points of error, and seasonality in acute and LTC facilities.

A retrospective review of 313 food service related PSLS reports from September 2017-September 2019 was completed. Data collected included point of error (receiving, food production, diet office, trayline, tray delivery, nursing), facility type (acute, LTC), facility name, degree of harm (critical, non-critical), and season. Data were analyzed in Microsoft Excel using descriptive statistics.

Of the 179 PSLS reports that met the inclusion criteria, 59.8% (n=107) were deemed critical. Between the three critical error types, texture errors were the most prevalent in both LTC and acute settings at 67% and 56% respectively. In LTC, the most common point of error was trayline (32.9%), followed closely by food production (30.6%). Diet office errors were most common in acute care (41.5%). Most critical errors occurred during the winter in LTC (39.5%), and during the fall in acute care (31.3%).

This study determined more than half of all reported food service related errors at Vancouver Coastal Health and Providence Health Care Sodexo sites are critical in nature, with textural errors being the most common.

This research will inform quality improvement initiatives in food service operations in order to help improve patient safety.