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Clinical Nutrition and Dietetics Risk Assessment: Patient Safety, Feeding Errors and Controls

A worked example of how a clinical nutrition and dietetics service finds, scores and controls risks to patient nutrition, safe feeding, documentation, consent and professional boundaries, from screening gaps to equipment failure.

Updated November 2026 8 hazards assessed Review every 6 months Highest risk: Critical to Medium
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Executive summary

This assessment shows how a clinical nutrition and dietetics service can find, rate and control risks that affect patient safety, nutrition care, documentation and professional boundaries. Eight risks were chosen because they arise in everyday ward and outpatient work. Missed malnutrition, refeeding syndrome and feeding prescription errors carry the highest inherent scores, so they receive the most attention. Each risk is scored before controls and again after existing and added controls. Most risks fall to Medium or Low once controls are in place, but refeeding and feeding errors stay at High until checks are tested in practice. The first actions are one screening tool, a written refeeding plan for high risk patients, standard diet order terms and a structured handover line. This is a teaching example, so the scores illustrate method and do not describe any real service. Specialist clinical review is needed for any real service.

Focus area
Clinical nutrition and dietetics
Setting
Inpatient and outpatient dietetic service in a general healthcare setting, working alongside nursing and medical teams
Method
Five by five likelihood and impact risk register

Scope

This assessment covers the dietetic service for adult inpatients on general wards and outpatient follow up, from nutrition screening and assessment to feeding support, documentation, referral and discharge advice. It looks at risks to patient safety, privacy, professional boundaries and continuity of care. It does not cover specialist pediatric, intensive care or research protocols. Jurisdiction, local protocols and clinical systems are assumptions made for teaching.

Context

The service has dietitians, dietetic assistants and a lead dietitian who sets standards. Nurses complete initial nutrition screening and record intake and weights. Catering staff prepare texture modified meals from diet orders, and enteral feeding uses pumps, sets and formula stored on the ward. Diet orders, referrals and assessments are held in an electronic record with a shared nutrition module. Each risk is scored before controls to show its natural level, then again after existing controls and the controls that should be added.

Objectives, assets and stakeholders

The objective is to meet the nutrition needs of each patient safely, prevent avoidable harm from feeding and diet errors, keep accurate and private records, respect professional scope and consent, and provide continuity across handovers and discharge. The assets in scope are patient nutrition and clinical records, feeding equipment, diet order systems, food and feed supplies, and the professional reputation of the dietetic team. Stakeholders include patients and their families, nurses, medical teams, catering and equipment staff, infection prevention staff, the clinical governance committee and the bodies that regulate professional practice. Each risk has one owner role, and the lead dietitian reports the register to clinical governance each quarter.

Risk matrix: before and after controls

Each cell shows hazard numbers placed by likelihood and impact. Compare the two grids to see how controls move each hazard.

Before controls

Inherent risk

Risk before controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely Likelihood 4, impact 3, score 12, high: H05 Likelihood 4, impact 4, score 16, high: H01 H02 Likelihood 4, impact 5, score 20, critical: H03
3 Possible Likelihood 3, impact 3, score 9, medium: H04 H08 Likelihood 3, impact 4, score 12, high: H06 H07
2 Unlikely
1 Rare

After controls

Residual risk

Risk after controls: rows are likelihood from almost certain to rare, columns are impact from insignificant to catastrophic. Cells list hazard numbers.
1
Insignificant		 2
Minor		 3
Moderate		 4
Major		 5
Catastrophic
5 Almost certain
4 Likely
3 Possible
2 Unlikely Likelihood 2, impact 2, score 4, low: H04 H08 Likelihood 2, impact 3, score 6, medium: H01 H02 H05 H06 Likelihood 2, impact 4, score 8, medium: H03
1 Rare Likelihood 1, impact 4, score 4, low: H07
  • Low 1 to 4
  • Medium 5 to 9
  • High 10 to 16
  • Critical 17 to 25

Hazard register

A summary first, then the detail for each hazard.

Summary of hazards with scores before and after controls
No.HazardBeforeAfterOwner
H01 Missed malnutrition or dehydration risk 16 High 6 Medium Lead dietitian
H02 Diet order and feeding prescription error 16 High 6 Medium Senior dietitian
H03 Refeeding syndrome not identified 20 Critical 8 Medium Consultant dietitian
H04 Consent, capacity and record keeping gaps 9 Medium 4 Low Clinical governance lead
H05 Handover and referral failure 12 High 6 Medium Ward manager
H06 Equipment and information system failure 12 High 6 Medium Equipment manager
H07 Infection and exposure control in feeding and food handling 12 High 4 Low Infection prevention lead
H08 Scope of practice and unsupported nutrition advice 9 Medium 4 Low Senior dietitian
H01

Missed malnutrition or dehydration risk

Safety Before 16 After 6

Patients at nutritional risk are not screened, or screening scores are not acted on, so weight loss, poor intake and dehydration go unnoticed until harm has developed.

Who or what is affected: Inpatients, families and ward nurses

Causes

Busy admission periods, unclear triggers and screening that is treated as paperwork.

Consequences

Preventable weight loss, pressure injury, slower recovery and longer stays.

Existing controls

  • A nutrition screening tool is completed on admission.
  • Weights are recorded on the ward chart each week.

Control gaps

Scores are recorded but not reviewed, so changes in intake are not picked up.

Additional controls

  • Prevent: Use one agreed screening tool with clear triggers for a full dietetic assessment.
  • Detect: Review overdue or unchanged screening scores at ward rounds each week.
Likelihood 4 x impact 4 before; 2 x 3 after Owner: Lead dietitian Target: Within 30 days Early warning: High risk screening scores with no dietetic review within 24 hours.
H02

Diet order and feeding prescription error

Safety Before 16 After 6

A diet order, texture, fluid limit, allergy flag or enteral feed rate is entered or transcribed wrongly, so the patient receives food or formula that does not match their clinical needs.

Who or what is affected: Patients with swallowing, allergy or metabolic needs, and catering and nursing staff

Causes

Free text orders, changing prescriptions and handovers during busy shifts.

Consequences

Aspiration, allergic reaction, dehydration or metabolic upset requiring urgent treatment.

Existing controls

  • A nurse checks each diet order against the meal at administration.
  • Allergy and texture fields are required on the electronic order.

Control gaps

Order changes are made by phone without a written update to the record.

Additional controls

  • Prevent: Use standard texture and fluid terms on every order and remove free text for allergies.
  • Respond: Stop the feed or meal, check the patient and report through the incident system at once.
Likelihood 4 x impact 4 before; 2 x 3 after Owner: Senior dietitian Target: Within 30 days Early warning: Diet order changes made without a dietetic or prescriber note.
H03

Refeeding syndrome not identified

Safety Before 20 After 8

A patient at high risk of refeeding syndrome starts full feeding without a written plan, electrolyte checks or dose adjustment, so phosphate, potassium and magnesium fall dangerously low.

Who or what is affected: Patients with prolonged low intake or high metabolic stress, and the medical team

Causes

Low screening awareness, delayed referral and feeding started at full dose by default.

Consequences

Cardiac or respiratory complications, neurological harm and possible death.

Existing controls

  • Refeeding risk is listed in the admission checklist.
  • Electrolytes are checked when a clinician requests them.

Control gaps

Checklist items are ticked without a plan, and checks depend on individual memory.

Additional controls

  • Prevent: Start a written refeeding plan for every high risk patient before feeding starts.
  • Detect: Check phosphate, potassium and magnesium at set intervals in the first days of feeding.
Likelihood 4 x impact 5 before; 2 x 4 after Owner: Consultant dietitian Target: Within 14 days Early warning: High risk patient started on full feeding without a written refeeding plan.
H04

Consent, capacity and record keeping gaps

Legal and compliance Before 9 After 4

Consent for tube feeding, capacity decisions and dietary advice are not recorded in full, or records are read or shared by staff who have no reason to see them, weakening care and privacy.

Who or what is affected: Patients, families and records staff

Causes

Time pressure, unclear capacity decisions and access rights that are not reviewed.

Consequences

Complaints, unlawful treatment claims, privacy breach and loss of trust.

Existing controls

  • Consent for tube feeding is recorded in the clinical notes.
  • Records are held on an access controlled electronic system.

Control gaps

Access rights are not reviewed after staff move wards or roles.

Additional controls

  • Prevent: Use a checklist for consent, capacity and feeding decisions in every tube feeding episode.
  • Detect: Audit a sample of records each month against the checklist and log any gaps.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Clinical governance lead Target: Within 60 days Early warning: Tube feeding started with the consent field blank.
H05

Handover and referral failure

People Before 12 After 6

Nutrition needs, review dates and open referrals are not passed on at shift change or transfer, so a patient is left without a dietetic plan or a timely review.

Who or what is affected: Patients moving between wards, nurses and the duty dietetic team

Causes

Busy shifts, unclear ownership of referrals and handovers given verbally only.

Consequences

Delayed feeding plans, missed reviews and avoidable deterioration.

Existing controls

  • Referrals are made through the electronic record.
  • Nursing handover includes a general nutrition line.

Control gaps

Referrals sit in the system without an acknowledgement or named reviewer.

Additional controls

  • Prevent: Use a structured handover tool with a nutrition line that names the next review date.
  • Respond: Escalate unresolved referrals to the duty dietitian within the same shift.
Likelihood 4 x impact 3 before; 2 x 3 after Owner: Ward manager Target: Within 45 days Early warning: Referrals open for more than two working days without a response.
H06

Equipment and information system failure

Technology and data Before 12 After 6

Enteral feeding pumps, alarms or the nutrition software fail, or a network outage prevents access to orders and charts, so feeds are interrupted or given at the wrong rate.

Who or what is affected: Tube fed patients, nurses and the dietetic team

Causes

Ageing devices, software updates, network faults and reliance on one system.

Consequences

Interrupted feeds, dehydration, wrong doses and delayed care.

Existing controls

  • Feeding pumps are serviced on a set schedule.
  • The nutrition software is backed up each night.

Control gaps

The paper fallback has not been tested, and spare sets are kept in a store away from the ward.

Additional controls

  • Prevent: Check pump alarms and feed rates at each handover and keep spare sets on the ward.
  • Recover: Test a manual paper fallback for orders and charts each quarter.
Likelihood 3 x impact 4 before; 2 x 3 after Owner: Equipment manager Target: Within 60 days Early warning: Pump alarm faults logged more than twice a week on one ward.
H07

Infection and exposure control in feeding and food handling

Safety Before 12 After 4

Enteral formula, food and feeding equipment are handled without hand hygiene, left open or kept past their use by time, so pathogens reach vulnerable patients and staff.

Who or what is affected: Immunocompromised and tube fed patients, catering staff and nurses

Causes

High workload, shared equipment and open feed containers left at bedside.

Consequences

Gastrointestinal infection, sepsis risk and extended stay.

Existing controls

  • Hand hygiene is required before any feeding support.
  • Patient food is prepared under the catering food safety plan.

Control gaps

Audit is occasional, and bedside storage rules are not enforced.

Additional controls

  • Prevent: Keep enteral formula and food in covered, dated containers and discard them after the set time.
  • Detect: Audit hand hygiene and feed handling during ward visits and feed back the results.
Likelihood 3 x impact 4 before; 1 x 4 after Owner: Infection prevention lead Target: Within 30 days Early warning: Feed containers found open or past their use by time on audit.
H08

Scope of practice and unsupported nutrition advice

Reputational Before 9 After 4

A dietitian or assistant gives supplement, diet or weight loss advice beyond their scope or the agreed evidence base, or without a prescriber or formulary reference, so patients are exposed to unsafe or unproven treatment.

Who or what is affected: Patients, families and the wider dietetic profession

Causes

Pressure from patients, commercial product offers and unclear limits on advice.

Consequences

Patient harm, professional complaints and damage to the service reputation.

Existing controls

  • Dietitians work within their registration and scope of practice.
  • Supplement advice follows a written formulary.

Control gaps

Advice notes are not sampled, and staff have not been asked to confirm their scope.

Additional controls

  • Prevent: Require prescriber sign off for any supplement or therapeutic diet outside the agreed formulary.
  • Detect: Review advice notes each quarter for claims outside the agreed evidence base.
Likelihood 3 x impact 3 before; 2 x 2 after Owner: Senior dietitian Target: Within 90 days Early warning: Supplement advice given without a documented prescriber or formulary reference.

Rating method and evaluation

Each risk is rated on two five point scales. Likelihood runs from 1, rare, to 5, almost certain, and impact runs from 1, minor, to 5, severe harm or loss of trust. Multiplying the two gives a score from 1 to 25 in one of four bands: Low from 1 to 4, Medium from 5 to 9, High from 10 to 16 and Critical from 17 to 25. The score guides the order of work and is not a measurement. Inherent risk is scored before controls, showing the natural level if nothing is done. Residual risk is scored after existing and additional controls. Residual must never be higher than inherent, and where inherent is 10 or more, residual must be lower. Impact considers physical harm, delay in care, cost, privacy breach and effect on trust, and patient harm is never rated down because it has not yet happened. Anything still High needs senior review and a dated plan, anything Medium needs routine controls with a named owner, and anything Low is accepted and monitored. Dietetic staff, nurses and patient representatives should challenge each rating at the quarterly review, and any rating is revisited when a warning indicator reaches its threshold.

Likelihood, impact and rating bands

Likelihood

  • 5 Almost certain: Expected to happen in most circumstances.
  • 4 Likely: Will probably happen in many circumstances.
  • 3 Possible: Could happen at some time.
  • 2 Unlikely: Not expected, but it could happen.
  • 1 Rare: Only in exceptional circumstances.

Impact

  • 1 Insignificant: No lasting effect. Handled within routine work.
  • 2 Minor: Small effect that is quickly corrected.
  • 3 Moderate: Noticeable effect that needs managed effort to correct.
  • 4 Major: Serious effect on people, delivery or reputation.
  • 5 Catastrophic: Severe or lasting effect that threatens the whole activity.

Bands (likelihood x impact)

  • Low (1 to 4): Accept and monitor.
  • Medium (5 to 9): Manage with routine controls.
  • High (10 to 16): Senior attention and a treatment plan.
  • Critical (17 to 25): Act first. Do not proceed until reduced.

Monitoring, escalation and review

Review this assessment every 6 months, and sooner when an indicator below reaches its threshold.

Early-warning indicators and escalation thresholds
Indicator to watchEscalate when
High risk screening scores with no dietetic review within 24 hours.Escalate to the lead dietitian when any case passes 24 hours, and to the clinical governance lead if it happens more than twice in a month.
Diet orders changed without a dietetic or prescriber note.Escalate to the ward manager on the same shift, and to the senior dietitian if repeated within a week.
Electrolyte checks missed during the first days of feeding for high risk patients.Escalate to the consultant dietitian and the medical team at once, and to clinical governance if any harm is found.
Pump alarm faults logged more than twice a week on one ward.Escalate to the equipment manager for review within one working day, and to the clinical governance lead if a feed was interrupted.
Consent fields blank on tube feeding episodes in the monthly record sample.Escalate to the clinical governance lead when the rate stays above the agreed level for a month, and to the privacy officer if data was exposed.

Contingency arrangements

If a serious event occurs, such as serious harm from a feeding error or a confirmed privacy breach, the ward manager stops the feed or diet, checks the patient and calls the medical team at once. The incident is reported through the local system and the lead dietitian informs the clinical governance lead the same day. Records are preserved, and the IT manager isolates affected accounts and restores data from the latest tested backup. Where equipment fails, staff use the tested paper fallback and spare sets. Patients and families are told what happened early and plainly, and any regulator or professional body contact follows local policy and specialist advice.

Prioritized action plan

  1. Adopt one nutrition screening tool with clear triggers for full assessment, owner lead dietitian, within 30 days.
  2. Write a refeeding plan for every high risk patient before feeding starts, owner consultant dietitian, within 14 days.
  3. Standardize diet order terms and remove free text for allergies, owner senior dietitian, within 30 days.
  4. Introduce a structured nutrition handover line and a duty dietitian escalation route, owner ward manager, within 45 days.
  5. Test the paper fallback for feeding orders and charts each quarter, owner equipment manager, within 60 days.

Conclusion

Safe nutrition care depends on steady habits: one screening tool, checked diet orders, a written refeeding plan for high risk patients, structured handover, consent recorded in full and equipment checked at each shift. The highest scores sit with missed malnutrition, feeding errors and refeeding syndrome, and each has actions that reduce the residual score. Treat the register as a living record, review it on the stated cycle and after any incident, and seek qualified clinical and professional advice for any real patient, legal or regulatory question.

Assumptions and limitations

Assumptions

  • The service works under a local clinical governance framework with named leads for nutrition, infection prevention and equipment.
  • Dietitians are registered and work within their scope of practice, with prescribers available for medical decisions.
  • Jurisdiction and specific clinical protocols are not specified, so legal and professional duties are described in general terms only.

Limitations

  • The scores are examples for learning and do not describe any real service, patient group or incident.
  • Clinical guidance on nutrition, feeding and refeeding changes over time and differs by setting, so specialist review is needed.
  • This is educational content and is not clinical, legal or professional advice for any real patient.

Related frameworks to study

  • Hierarchy of controls
  • Clinical governance cycle with audit and feedback
  • Structured handover tools such as SBAR
  • Incident reporting and root cause analysis

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For Learning Reference Only: This assessment demonstrates how risk assessment principles are applied in a practical setting, providing a useful reference for learning and understanding. Actual assessments may be adapted to suit specific site conditions and circumstances.

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