A nurse inadvertently gave juice to a patient who was NPO due to a procedure because the NPO status was not communicated by the primary nurse or posted on the patient's board, and the electronic chart still showed a general diet.

Workarounds Described

• Relies on whiteboard or verbal handoff to communicate NPO status
• Checks patient chart manually but may have outdated diet order

Implied Software Gaps

• Real-time communication tool that instantly updates NPO status across all platforms and alerts all staff
• Automated EHR check that flags conflicts (e.g., diet order vs. NPO status) and prompts re-verification

NPO Status Alert System

A real-time patient safety app that syncs with the EHR to flag NPO status and dietary restrictions, ensuring every nurse has immediate access to up-to-date information. It provides visual alerts, automatic notifications, and a quick-access mobile view to prevent errors like giving food/fluid to a patient who is NPO.