What International Patient Safety Goal is most relevant when a child with a peanut allergy experiences an acute asthma exacerbation?

International Patient Safety Goal: Decrease Mistakes Due to Miscommunication (Option C)

The most relevant International Patient Safety Goal in this scenario is Option C: Decrease mistakes due to miscommunication, as the critical peanut allergy information was discovered during handover—a high-risk transition point where communication failures can lead to life-threatening consequences, particularly in a child with comorbid asthma who is at significantly increased risk for severe anaphylaxis. 1

Why Communication Safety is Paramount in This Case

The Critical Link Between Asthma and Food Allergy Severity

• Children with comorbid asthma and food allergy face dramatically elevated risks of severe anaphylactic reactions and emergency department utilization. 1
• African American and Hispanic children with food allergy demonstrate significantly greater odds of comorbid asthma and increased rates of food-induced anaphylaxis, placing them at greater risk of adverse food allergy outcomes 1
• Peanut allergy is one of the leading causes of fatal and near-fatal food-induced anaphylactic reactions, making accurate communication of this allergy status absolutely critical 2, 3

Handover as a High-Risk Communication Point

• The handover period represents a critical juncture where miscommunication can result in failure to recognize and respond to the peanut allergy, potentially leading to accidental exposure during the acute asthma exacerbation management
• During acute medical situations like asthma exacerbations, the risk of overlooking allergy information increases if not properly communicated between healthcare providers
• Effective communication during transitions of care is essential to ensure all providers are aware of the peanut allergy and can avoid peanut-containing medications, foods, or environmental exposures 1

Why Other Options Are Less Relevant

Option A: Preoperative Surgical Checklist

• Not applicable as this scenario involves an acute medical emergency (asthma exacerbation), not a surgical procedure
• Surgical checklists are designed for operative settings, not acute medical management

Option B: Identify Patient Correctly by Using Two Identifiers

• While patient identification is always important, the critical safety issue here is not misidentification but rather failure to communicate known allergy information during handover
• The patient's identity is presumably already established; the problem is information transfer about the peanut allergy

Clinical Implications of the Communication Failure

Immediate Risks During Acute Asthma Management

• Hospital-based emergency management with intramuscular epinephrine increased from 12% to 25% during 2011-2014 for food-induced anaphylaxis, highlighting the severity of these reactions 1
• Intensive care unit admissions and fatal reactions occurred in 1.3% of pediatric anaphylaxis cases in the European Anaphylaxis Registry 1
• The combination of acute asthma and potential peanut exposure creates a perfect storm for severe, potentially fatal anaphylaxis

Common Pitfalls to Avoid

• Never assume allergy information has been communicated during handover—always verify directly
• Be aware that peanut can be present in unexpected sources during hospital care (medications with peanut oil, food service items, even airborne exposure in certain settings)
• Children with asthma require heightened vigilance for anaphylaxis management, as respiratory symptoms may be attributed to asthma rather than recognized as anaphylaxis 1

Structured Communication Protocol for This Scenario

Essential elements that must be communicated during handover:

1. Explicit statement of peanut allergy status with severity of previous reactions
2. Current acute asthma exacerbation status and treatment
3. Availability and location of epinephrine autoinjector 1
4. Anaphylaxis action plan if one exists
5. Any history of previous anaphylactic reactions and triggers

The discovery of the peanut allergy during handover represents a near-miss event that underscores the critical importance of standardized communication protocols to prevent medication errors, dietary exposures, and delayed recognition of anaphylaxis in this high-risk population. 1, 4