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

BACKGROUND

Wrong meal tray deliveries in hospital settings pose a significant threat to patient safety, particularly for individuals with dietary restrictions due to dysphagia, allergies, or feeding assistance needs.

OBJECTIVE

To implement a multipronged quality improvement intervention aimed at reducing wrong meal tray deliveries and associated high-risk dietary errors in an inpatient rehabilitation setting.

METHODS

A pre-postintervention study was conducted using data from an internal event reporting system from May 2023 to February 2025. Interventions included wristband scanning, dietary-nursing handoff forms for 1:1 feeds, dedicated meal carts, communication protocols, and nursing education on the International Dysphagia Diet Standardization Initiative (IDDSI) diet levels. Errors were classified by clinical severity and type: high-risk errors (including allergen exposures or incorrect textures), wrong-patient or wrong-tray errors (without immediate clinical harm), and administrative/documentation errors.

RESULTS

When normalized to patient-days, the overall meal tray error rate declined significantly postintervention (1.83 versus 0.65 errors per 1000 patient-days; P=0.025). High-risk errors (those involving allergen exposure or aspiration risk) declined by over 80%, representing the most clinically meaningful improvement observed.

CONCLUSIONS

A targeted, systems-based intervention can significantly reduce high-risk dietary errors in the inpatient setting. Sustained success will require continued compliance auditing, feedback loops, and ongoing education.