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Thibault R, Abbasoglu O, Ioannou E, et al. Clin Nutr. 2021;40:5684-5709.
Mistakes in hospital dietary services can contribute to allergic reactions and patient malnourishment. This guidance shares an improvement approach to care environment food provision that considers clinical concerns and patient limitations as steps toward enhancing patient care.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.
After undergoing a complete atrioventricular canal defect repair, an infant with trisomy 21 was transferred to the pediatric intensive care unit (PICU) and total parenteral nutrition (TPN) was ordered due to low cardiac output. When the TPN order expired, it was not reordered in time for cross-checking by the dietician and pediatric pharmacist and the replacement TPN order was mistakenly entered to include sodium chloride 77 mEq/100 mL, a ten-fold higher concentration than intended.
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
Decerbo M. Pharmacy Practice News. September 13, 2018.
Parenteral nutrition errors can result in patient malnutrition and harm. Reporting on how insufficient understanding of malnutrition contributes to its presence in health care, this news article suggests that both general guidelines and tailored approaches to nutrition are necessary to keep hospitalized patients safe. Improvements in addressing the complicated needs of patients who are older or have cancer illustrate progress made toward the effective delivery of nutrition.
Boullata JI, Carrera AL, Harvey L, et al. JPEN J Parenter Enteral Nutr. 2017;41:15-103.
Enteral nutrition is provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead to safety hazards. Drawing from current evidence, these consensus guidelines recommend best practices to ensure safety of enteral nutrition, including a six-step standardized approach to administering eternal nutrition that involves independent double-checks and automation with forcing functions.
Xu T, Wick EC, Makary MA. BMJ Qual Saf. 2016;25:311-314.
This commentary explores elements of the hospital environment that can contribute to sleep deprivation and malnutrition in patients, including care complexity, hospital census, poor communication, and noise. The authors advocate for designing more patient-centered hospital systems to prevent this type of harm.
Guenter P, Jensen G, Patel V, et al. Jt Comm J Qual Patient Saf. 2015;41:469-473.
Previous studies have explored safety issues related to parenteral nutrition processes, but problems associated with general nutrition for inpatients have received scant attention. This commentary advocates for promoting awareness around malnutrition as a hospital-acquired condition and outlines 12 actions to improve the safety of nutrition care for hospitalized patients, including use of routine assessments and checklists.
Guenter P, Boullata JI, Ayers P, et al. Nutr Clin Pract. 2015;30:570-6.
Parenteral nutrition has the potential to result in patient harm if administered or prepared incorrectly. This commentary builds on a set of overarching recommendations to define competencies that enable the safe prescribing and delivery of parenteral nutrition. The model is designed to help organizations apply the suggestions in their particular care environments.
Wallace SC. PA-PSRS Patient Saf Advis. 2015;12:62-70.
This article analyzed data on dietary errors submitted to a state reporting program and found that more than 60% of patients received trays containing food items to which they were allergic. Recommendations to prevent such errors include standardizing practices and using whiteboards as communication tools.
Clark C. HealthLeaders Media. September 18, 2014.
This news article explores the validity of recent reports by an interdisciplinary consortium that one in three hospitalized patients is malnourished and suggests further research is required to understand this potential patient safety problem.
Ayers P, Adams S, Boullata J, et al. Nutr Clin Pract. 2014;29:277-82.
This commentary describes strategies to promote the use of parenteral nutrition safety guidelines in practice. The authors include examples of how checklists can improve adoption of best practices and discuss the potential for instituting policies and providing information about drug shortages to drive integration of the recommendations into daily work.
Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-34.
This review surveys information on enteral nutrition administration and tubing misconnections and recommends employing increased standards and forcing functions to reduce their incidence.
American Society for Parenteral and Enteral Nutrition; ASPEN.
This Web site includes a toolkit, posters, and educational materials to support safe tube feedings and prevent tubing misconnections. 
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2008. Report No. OEI-02-08-00140.
This report summarizes 2007 data on quality and safety issues in Medicare- and Medicaid-certified nursing homes and finds that 17% of the organizations were cited for care deficiencies that could result in harm to residents.