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Should known allergy status be included as a medication administration 'right'?
1Associate Professor, Department of Nursing, Faculty of Medicine and Health Sciences, Universiti of Malaysia, UNIMAS, Sarawak, Malaysia.
Insights
A paediatric case study highlights medication errors due to unacknowledged allergies. Researchers recommend including known allergy status as a critical
Area of Science:
- Medical Safety
- Paediatric Care
- Clinical Risk Management
Background:
- Medication errors pose a significant risk in healthcare, particularly for vulnerable paediatric patients.
- Current medication administration protocols often overlook the critical importance of documented known allergy status.
- Paediatric patients rely on advocates due to their inability to communicate allergies effectively.
Purpose of the Study:
- To analyze a paediatric case study involving an anaphylactic reaction caused by failure to acknowledge a known allergy.
- To re-evaluate the 'rights of medication administration' in light of medication safety literature gaps.
- To advocate for the inclusion of known allergy status as a distinct medication administration 'right'.
Main Methods:
- Case study analysis of a paediatric anaphylactic reaction.
- Literature review of medication administration rights and medication safety.
- Examination of multidisciplinary team's handling of patient allergy information.
Main Results:
- A 3-year-old child experienced an anaphylactic reaction due to the healthcare team's failure to recognize their documented allergy.
- Existing 'rights of medication administration' frameworks do not explicitly include known allergy status.
- Medication safety literature lacks sufficient emphasis on patient allergy status verification.
Conclusions:
- Known allergy status should be integrated as the second medication administration 'right'.
- This inclusion is crucial before prescribing, transcribing, dispensing, and administering any medication.
- Transparent verification of known allergy status is vital for preventing medication errors in paediatric care.
Abstract:
This article employs a paediatric case study, involving a 3-year-old child who had an anaphylactic reaction that occurred as a result of the multidisciplinary team's failure to identify and acknowledge the patient's documented 'known allergy' status. It examines and reconsiders the ongoing healthcare dilemma of medication errors and recommends that known allergy status should be considered the second medication administration 'right' before the prescribing, transcribing, dispensing and administration of any drug. Identifying and documenting drug allergy status is particularly important when caring for paediatric patients, because they cannot speak for themselves and must rely on their parents, guardians or health professionals as patient advocates. The literature states that medication errors can be prevented by employing a 'rights of medication administration' format, whether that be the familiar '5 rights' or a more detailed list. However, none of these formats specify known allergy status as a distinct 'right'. The medication safety literature is also found wanting in respect of the known allergy status of the patient. When health professionals employ a medication administration rights format prior to prescribing, transcribing, dispensing or administering a medication, the 'known allergy status' of the patient should be a transparent inclusion.
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