Understanding nutrition as a patient safety problem: an audit of South Australian practices

Michelle Schilling

Country Health SA Local Health Network (Port Lincoln site) PO Box 630, Port Lincoln, SA, 5606, michelle.schilling@sa.gov.au


There is evidence to indicate that poor nutritional care can threaten the safety of people in hospital and community settings leading to increased mortality and morbidity (1). Nutritional care crosses diagnostic, professional and jurisdictional boundaries and can impact a range of health care stakeholders. The aim of this initiative was to provide an overview of, and quantify, the number of nutrition-related patient safety incidents reported in SA Health’s Safety Learning System (SLS) and a summary of themes and contributing factors reported in this data.


Incidents reported in the SLS as occurring during one calendar year (2015) were searched for nutrition-related keywords using a free text search. Nineteen nutrition-related keywords were used to generate incident reports which were reviewed for nutrition-related incidents against the nutrition-related patient safety incident definition.  Nutrition-related incidents were attributed to one or more key themes.


The findings from this audit indicated that the most commonly reported patient safety nutrition-related incident themes were aspiration/choking, problem with meal or feed preparation and/or delivery, and fasting-related. Contributing factors were poor and lack of timely communication between staff and departments/services, and problems relating to ordering (misinterpretation or incorrect ordering), incorrect/delayed prescription and delivery of feed/food/fluids.


Health care organisations should recognise that poor nutrition care practices can cause unnecessary harm to patients, resulting in poor quality health care. Despite its impact, currently nutrition-related patient safety incidents are under reported and/or hidden in other patient safety incident areas resulting in missed opportunities for improvements.

  1. Dietitians of Australia. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutr Diet 2009; 66(Suppl.): S1-S34.


Michelle Schilling is a local Port Lincoln resident with a Masters in Nutrition and Dietetics. She has been working as a Dietitian in South Australia for the past 15 years within country and metropolitan health services. Michelle’s current job role focuses on the quality, safety and effectiveness of Dietitian services across Country Health South Australia Local Health Network. Her contribution to the Dietetics profession involves an earlier history of Dietitians Association of Australia committee work, journal publications and more recently within South Australia’s diminished community nutrition / public health areas.

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