Allergy Safety Events in Health Care: Development and Application of a Classification Schema Based on Retrospective...

Area of Science:

• Health care safety research
• Patient safety
• Allergy management

Background:

• Allergy safety necessitates understanding operational processes and failures leading to patient allergen exposure.
• Identifying failure points is key to preventing adverse events for allergic patients.

Purpose of the Study:

• To develop and assess a classification schema for allergy safety events.
• To describe failures resulting in allergy-related safety events in health care settings.

Main Methods:

• Analysis of 299,031 voluntarily-filed safety event reports from two academic medical centers over five years.
• Utilized keyword searches and expert manual review to identify and classify allergy-related safety events.
• Employed driver diagrams to determine root causes of common allergy safety events.

Main Results:

• Identified 744 (0.2%) allergy-related safety events from the analyzed reports.
• Key failure categories included electronic health record (EHR) documentation errors (50.4%), human factors (23.5%), and EHR alert issues (17.1%).
• Exposures involved drugs (e.g., heparin), latex, food allergens, and adhesives.

Conclusions:

• A novel safety failure classification schema was informed by 744 identified allergy-related safety events.
• This schema is a significant step towards enhancing health care safety for patients with allergies.
• System improvements are needed to address specific safety concerns related to food and drug allergens.