The patient safety threats no one talks about

Threats to patient safety such as hospital-acquired infections, patient falls and medical errors make nationwide headlines, but lesser-known safety threats such as dietary errors and hazardous antiseptic products may slip under the radar.

Between January 2009 and June 2014, the Pennsylvania Patient Safety Authority identified 285 dietary errors in healthcare facilities, eight of which resulted in serious patient harm. The most common errors were:

  • Serving patients food they were allergic to, which represented 181 of the cases and was the cause for all eight incidents of serious harm
  • Providing the patients with food that weren't on their diets (50 cases)
  • Giving patients food meant for other other patients (43 cases)
  • Serving food to patients, such as preoperative patients, who were not to receive food by mouth (11 cases)

The Authority interviewed dietary directors and clinical dietitians from around the Keystone State and compiled numerous strategies for preventing such errors. Best practices include written guidance for handling allergies and special diets; continual allergy/special diet education and training for healthcare workers; checking for at least two patient identifiers before delivering a food tray to a patient; and using only listed ingredients for recipes rather than making substitutions.

Meanwhile, the Food and Drug Administration recently issued a proposed rule on the safety of over-the-counter antiseptics used in healthcare environments, such as personnel handwashes and rubs, surgical hand scrubs and preoperative skin preparation. The agency is primary concerned with long-time exposure and potential adverse events that could occur as a result of the exposure, Theresa Michele, M.D., director of the agency's division of nonprescription drug products in the center for drug evaluation and research, told Medscape.  

"As an intensive care unit physician, I can tell you that we use these products up to 100 times every shift--every time you enter a patient's room, and every time you exit a patient's room," she told the publication. "Thus, even small amounts of absorption might add up over the long term. That's what we are looking at."

To learn more:
- here's the article on the Pennsylvania Patient Safety Authority findings
- read the Medscape interview

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