1621 - Reducing High-Risk Meal Tray Delivery Errors in Inpatient Rehabilitation Through Wristband Scanning and Interdisciplinary Workflow Optimization

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. Objectives for this project are to implement a multi-pronged quality improvement intervention aimed at reducing wrong meal tray deliveries and associated Tier 1 safety risks in an inpatient rehabilitation setting.

Design: A pre-post intervention study was conducted using data from an internal event reporting system between June 2023 and April 2025. Interventions included wristband scanning, dietary-nursing handoff forms for 1:1 feeds, dedicated meal carts, communication protocols, and nursing education on IDDSI diet levels. Error frequencies and severity were stratified by patient safety tiers (Tiers 1–3).

Results:

Preliminary results show that overall meal tray errors decreased significantly post-intervention. Tier 1 errors—those associated with allergen exposure or aspiration risk—declined by over 80%. These changes reflect improved consistency in meal tray verification and workflow reliability.

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.