International Patient Safety Goal for Peanut Allergy During Acute Asthma Exacerbation
The correct answer is C: Decrease mistakes due to miscommunication. This case directly exemplifies the critical need for effective communication during handover to prevent potentially fatal outcomes from inadvertent allergen exposure.
Why Communication is the Priority Safety Goal
The handover period represents the most dangerous communication transition in healthcare where critical allergy information must be accurately transmitted to prevent fatal anaphylaxis from inadvertent peanut exposure during hospitalization. 1, 2 This scenario specifically involves discovering a peanut allergy during handover while managing an acute asthma exacerbation—a situation where communication failure could be catastrophic.
Compounded Risk in This Patient
- Patients with concurrent asthma and peanut allergy face dramatically elevated risks, as asthma is the strongest risk factor for fatal food-induced anaphylaxis. 1, 2
- Respiratory symptoms from anaphylaxis may be misattributed to the acute asthma exacerbation, delaying recognition and treatment of a potentially fatal allergic reaction. 2
- Peanuts cause the majority of fatalities from food-induced anaphylaxis, making accurate communication of this allergy absolutely essential. 1
Critical Communication Elements Required
The following allergy information must be communicated during every handover to prevent adverse outcomes: 1
- Specific allergen identification (peanut)
- Cross-reactivity risks and severity of previous reactions
- Emergency medication availability (confirmation that two epinephrine autoinjectors are immediately accessible)
- Asthma control status (particularly critical in this case)
- Documentation of previous reaction severity
Why the Other Options Are Incorrect
Option A: Preoperative Surgical Checklist
- This patient is experiencing an acute medical condition (asthma exacerbation), not undergoing surgery
- While surgical checklists are important safety tools, they are not applicable to this medical scenario
Option B: Identify Patient Correctly Using Two Identifiers
- While patient identification is always important, the critical safety issue here is communicating the newly discovered allergy information to prevent exposure
- The patient's identity is not in question—the risk is that providers may inadvertently expose the patient to peanut-containing medications, foods, or environmental sources if the allergy is not effectively communicated 2
Immediate Actions Upon Discovery
Upon discovering the peanut allergy during handover, the provider must: 1
- Document allergy prominently in all systems with reaction severity
- Verify epinephrine availability and location
- Review all current medications for peanut-derived ingredients or cross-contamination risk
- Communicate to dietary services with strict avoidance orders and cross-contamination precautions
- Optimize asthma control to reduce compounded risk
Common Communication Pitfalls to Avoid
- Never assume allergy information has been communicated during handover—always verify directly. 2
- Delayed epinephrine administration has been implicated in contributing to fatalities from anaphylaxis, often because allergy information was not effectively communicated to responding providers. 1
- Oral tingling or mild symptoms can rapidly progress to life-threatening anaphylaxis within minutes, requiring immediate recognition and treatment. 1
- Biphasic reactions occur in 1-20% of cases, requiring 4-6 hours observation even after initial symptom resolution. 1