Addressing disease-related malnutrition in hospitalized patients: a call for a national goal. | PSNet

Provide Feedback |

Submit a Case

Register

Commentary

Addressing disease-related malnutrition in hospitalized patients: a call for a national goal.

September 30, 2015

Guenter P, Jensen G, Patel V, et al. Jt Comm J Qual Patient Saf. 2015;41(10):469-473.

View more articles from the same authors.

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.

PubMed citation

Related Resources From the Same Author(s)

The source of purchased medications and its impact on medication mistakes and hospitalizations.

March 16, 2022

Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model.

July 8, 2015

New enteral connectors: raising awareness.

December 3, 2014

Parenteral nutrition errors and potential errors reported over the past 10 years.

March 14, 2018

Enteral feeding misconnections: an update.

June 17, 2009

Tubing misconnections: normalization of deviance.

June 29, 2011

Cognitive bias impact on management of postoperative complications, medical error, and standard of care.

November 4, 2020

ASPEN Safe Practices for Enteral Nutrition Therapy.

December 14, 2016

ASPEN parenteral nutrition safety consensus recommendations: translation into practice.

May 14, 2014

A literature review of the individual and systems factors that contribute to medication errors in nursing practice.

September 16, 2009

Comorbid conditions delay diagnosis of colorectal cancer: a cohort study using electronic primary care records.

July 26, 2017

The patient is in: patient involvement strategies for diagnostic error mitigation.

September 4, 2013

Primary care closed claims experience of Massachusetts malpractice insurers.

October 16, 2013

Who makes prescribing decisions in hospital inpatients? An observational study.

May 30, 2012

Enteral feeding misconnections: a consortium position statement.

May 7, 2008

Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review.

January 12, 2011

Multi-level strategies to achieve resilience for an organisation operating at capacity: a case study at a trauma centre.

May 30, 2007

Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis.

July 15, 2015

Standardized Competencies for Parenteral Nutrition Administration: the ASPEN Model.

June 20, 2018

The mindful path to nursing accuracy: a quasi-experimental study on minimizing medication administration errors.

May 19, 2021

Avoiding a Med-Wreck: a structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources.

March 3, 2021

Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout.

March 3, 2021

Diagnostic error in internal medicine.

July 27, 2005

Testing the association between Patient Safety Indicators and hospital structural characteristics in VA and nonfederal hospitals.

November 18, 2009

Group urges going metric to head off dosing mistakes.

June 18, 2014

Instituting vincristine minibag administration: an innovative strategy using simulation to enhance chemotherapy safety.

December 6, 2017

Developing perioperative Covid-19 testing protocols to restore surgical services.

July 22, 2020

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system.

September 20, 2023

Association of provider specialty with abortion-related morbidity and adverse events among patients having procedural and medication abortions.

August 10, 2022

Adaptation and implementation of the WHO Safe Childbirth Checklist around the world.

November 3, 2021

Opportunities to improve informed consent with AHRQ training modules.

June 13, 2018

Improving diagnosis: adding context to cognition.

September 7, 2022

A controlled trial of a rapid response system in an academic medical center.

June 25, 2008

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

February 8, 2017

The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study.

August 28, 2013

"Free lessons" in aviation safety.

March 6, 2005

Unannounced versus announced hospital surveys: a nationwide cluster-randomized controlled trial.

May 3, 2017

Non-emergency patient transport: what are the quality and safety issues? A systematic review.

February 2, 2011

What constitutes effective team communication after an error?

May 27, 2020

Accuracy of adverse-drug-event reports collected using an automated dispensing system.

July 6, 2005

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review.

February 1, 2023

A national profile of patient safety in U.S. hospitals.

March 6, 2005

Risk of adverse drug events by patient destination after hospital discharge.

September 21, 2005

Associations between perceived crisis mode work climate and poor information exchange within hospitals.

February 4, 2015

Vulnerability of the medical product supply chain: the wake-up call of COVID-19.

November 25, 2020

What near misses tell us about risk and safety in mental health care.

November 30, 2011

A transdisciplinary team acting on evidence through analyses of moot malpractice cases.

July 11, 2007

Central venous catheter guidewire retention: lessons from England's never event database.

May 4, 2022

The architecture of safety: an emerging priority for improving patient safety.

November 21, 2018

On the scene at Children's Hospitals and Clinics of Minnesota.

January 14, 2009

How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care.

July 12, 2023

Associations between self-reported healthcare disruption due to COVID-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England.

August 9, 2023

COVID-19: making the right diagnosis.

August 5, 2020

An initiative to reduce insulin-related adverse drug events in a children's hospital.

February 16, 2022

The thinking doctor: clinical decision making in contemporary medicine.

August 31, 2016

Intersystem medical error discovery: a document analysis of ethical guidelines.

January 12, 2022

Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds.

June 29, 2005

Can mindfulness in health care professionals improve patient care? An integrative review and proposed model.

June 12, 2019

Improving patients' intensive care admission through multidisciplinary simulation-based crisis resource management: a qualitative study.

September 20, 2023

The global burden of diagnostic errors in primary care.

August 24, 2016

JAMA professionalism: disclosure of medical error.

August 24, 2016

Medication discrepancies upon hospital to skilled nursing facility transitions.

April 29, 2009

Caregiver fatigue: implications for patient and staff safety—part 1 and part 2.

September 7, 2016

Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors.

May 8, 2013

Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience.

March 7, 2018

Nursing bedside clinical handover—an integrated review of issues and tools.

November 12, 2014

The lost art of doctoring: reflections of a pediatric resident.

November 15, 2017

Critical events in the lives of interns.

November 19, 2008

Negotiating safety when staffing falls short.

June 30, 2010

Using patient safety indicators to estimate the impact of potential adverse events on outcomes.

January 30, 2008

Drug shortages: a complex health care crisis.

May 7, 2014

Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning.

November 4, 2015

Integrating computerized clinical decision support systems into clinical work: a meta-synthesis of qualitative research.

November 4, 2015

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

January 23, 2008

Prolonged diagnostic intervals as marker of missed diagnostic opportunities in bladder and kidney cancer patients with alarm features: a longitudinal linked data study.

February 17, 2021

Impact of repeated reimbursement penalties on hospital total quality scores.

April 17, 2024

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: a multi-centre study.

March 11, 2020

Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections.

February 12, 2014

Responsible e-prescribing needs e-discontinuation.

February 15, 2017

Iatrogenesis in the context of residential dementia care: a concept analysis.

August 3, 2022

Cultivating a culture of medication safety in prelicensure nursing students.

April 8, 2015

What words convey: the potential for patient narratives to inform quality improvement.

April 24, 2019

Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.

November 21, 2007

Characterising 'near miss' events in complex laparoscopic surgery through video analysis.

May 27, 2015

The use of a standard design medication room to promote medication safety: organizational implications.

February 13, 2013

Patient safety room of horrors: a novel method to assess medical students and entering residents' ability to identify hazards of hospitalisation.

March 9, 2016

Evaluating the Patient Safety Indicators: how well do they perform on Veterans Health Administration data?

September 7, 2005

Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review.

April 13, 2016

The safe day call: reducing silos in health care through frontline risk assessment.

September 24, 2014

Hospital at night: an organizational design that provides safer care at night.

August 10, 2016

Unfinished nursing care, missed care, and implicitly rationed care: state of the science review.

April 8, 2015

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.

May 8, 2019

A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.

July 17, 2013

Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events.

May 18, 2011

Electronic fetal heart rate monitoring: applying principles of patient safety.

May 16, 2012

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

December 7, 2022

Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error.

April 8, 2009

The vulnerabilities of computerized physician order entry systems: a qualitative study.

December 9, 2015

Deploying med reconciliation.

April 30, 2008

The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals—a retrospective record review study.

February 8, 2017

View More

Related Resources

Nutrition Support Safety.

February 7, 2024

Comparing perspectives on organisational silence: an analysis of the Gosport inquiry.

May 17, 2023

Medical line entanglement: the unspoken patient safety hazard of medical devices.

May 3, 2023

A decade after Francis: is the NHS safer and more open?

April 5, 2023

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.

March 29, 2023

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors.

October 12, 2022

Moving beyond implicit bias in antiracist academic medicine initiatives.

September 7, 2022

Criminal liability for nursing and medical harm.

August 3, 2022

Who killed patient safety?

July 20, 2022

Physician liability in the age of data reliance and errors.

March 16, 2022

ESPEN guideline on hospital nutrition.

February 9, 2022

"Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation.

January 19, 2022

Malnutrition in Hospitalized Adults: A Systematic Review.

October 27, 2021

A roadmap to advance patient safety in ambulatory care.

January 20, 2021

Transformational improvement in quality care and health systems: the next decade.

November 25, 2020

An effective intervention: limiting opioid prescribing as a means of reducing opioid analgesic misuse, and overdose deaths.

September 23, 2020

To err Is human, unless you are a healthcare provider.

August 3, 2020

The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies.

July 29, 2020

Apology laws and malpractice liability: what have we learned?

July 8, 2020

The patient died: what about involvement in the investigation process?

June 24, 2020

Preventing a parallel pandemic - a national strategy to protect clinicians' well-being.

June 10, 2020

WebM&M Cases

Life-Threatening Infant Overdose of Sodium Chloride

May 27, 2020

Annals Clinical Decision Making: avoiding cognitive errors in clinical decision making.

May 20, 2020

Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality.

May 13, 2020

WebM&M Cases

The Need to Eat

December 18, 2019

Unleash the power of patients to make care safer around the world: an essay by Helen Haskell.

September 25, 2019

Increasing compliance of safe medication administration in pediatric anesthesia by use of a standardized checklist.

June 19, 2019

Reducing avoidable medication-related harm: what will it take?

May 8, 2019

Recommendations from a national panel on quality improvement in obstetrics.

April 24, 2019

View More

See More About The Topic

Nutrition/Dietetics

Epidemiology of Errors and Adverse Events

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364