In March this year, a 75-year-old male patient in Caritas Medical Centre (CMC) who was supposed to be on a liquid diet was suspected to have been fed a normal meal incorrectly, resulting in a throat obstruction and ultimately dying after unsuccessful attempts at resuscitation.
CMC announced the incident afterward and a Root Cause Analysis Panel was formed to analyse the incident. After reviewing the case, the Panel concluded that the root cause of the incident was the varied interpretations of the term DAT (abbreviation of the term "diet as tolerated"), which led to communication gaps and misaligned practices among the clinical team.
The Panel considered that multiple factors were involved in this sentinel event. There was a lack of communication between the medical and nursing staff regarding dietary orders. The inclusion of a DAT as a standard diet type in some electronic systems might have created the perception that the instruction referred to a specific diet type. Additionally, some nursing teaching materials equate the term with a regular diet, which could also have contributed to varied understanding in daily clinical practice.
The Panel made the following recommendations: The interpretation of the term DAT should be aligned and communicated to staff; The use of DAT as a diet type option in all forms and electronic systems should be removed to eliminate ambiguity; The dietary management workflow from patient assessment to communication to meal provision should be enhanced; and the terminology for diet options in the Dietetics and Catering Order System should be standardised with the electronic bed panel system. The interface between these systems should be improved to synchronise data and minimise the risk of misinterpreting dietary orders.
The Hospital Authority (HA) has aligned the definition of the term DAT. It is now explicitly defined as a flexible dietary approach tailored to the patient's individual tolerance, preferences, and medical condition, subject to professional assessment. It does not imply any specific food texture.
The spokesperson said that CMC will implement the relevant recommendations to enhance medical and nursing staff training to ensure proper understanding and implementation of the aligned definition of the term concerned in daily practice. The hospital has met with the patient's family to explain the report's findings, and expressed deep condolences to the family members. CMC will maintain communication with the family and provide necessary assistance.
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