Background/Aims: The Children’s Hospital at Westmead (Sydney Children’s Hospitals Network), is a tertiary paediatric hospital with 312 inpatient beds. The Food Service Department operates a cook fresh food production system using 3 plating lines a day. There are more than 85 special diets. A series of incidents in 2014 involving a patient diagnosed with anaphylaxis to multiple food allergens required formal investigation of risks from food to clinical management and inpatient safety. One incident resulted in harm to the individual requiring a five hour admission to the paediatric intensive care unit. In two incidents a “special” nurse was bedside however, despite training in anaphylaxis management, neither nurse appeared to recognise the risk to the patient presented by food.
Methods: Ingredient compliance with diet codes, the range of diet codes, meal ordering, food production, plating and distribution procedures were examined and mapped generating significant changes across the system. Communication methods were also reviewed.
Results: The two consequent investigations of these incidents identified multiple points of risk throughout the food production process. The diets at greatest risk were those requiring strict accuracy of content with minimal tolerance for error. These included multiple allergy diets, some metabolic diets and the ketogenic diet.
Conclusions:There are multiple points of risk to inpatient safety along a streamlined food provision pathway in a hospital. Significant changes have been made to mitigate risk at various points however 100% risk free is not achievable. Heightened awareness of all concerned appears to be key.
Funding Source: N/A