International Patient Safety Goal for Handover Communication Failure
The International Patient Safety Goal that applies to this case is Goal 2: Improve Effective Communication, specifically addressing miscommunication during patient handover that resulted in failure to communicate critical allergy information. 1
Why This is a Communication Failure, Not Patient Identification
The scenario describes a provider discovering the peanut allergy during handover—meaning the patient's identity was already established, but critical safety information (the peanut allergy) was not effectively communicated between care teams. 1 This represents a breakdown in handover communication, which is recognized as the most dangerous communication transition in healthcare where critical allergy information must be accurately transmitted to prevent fatal anaphylaxis. 1
Understanding the International Patient Safety Goals
The World Health Organization and Joint Commission identify specific patient safety goals:
Goal 1 (Option A): Identify Patients Correctly addresses using two patient identifiers (name, date of birth, medical record number) to ensure the right patient receives the right treatment. 2 This goal prevents wrong-patient errors but does not address information transfer failures.
Goal 2 (Option B): Improve Effective Communication specifically targets communication failures during handovers, verbal orders, and critical test results. 1, 3 The failure to communicate a known peanut allergy during handover directly falls under this goal.
Goal 4 (Option C): Ensure Correct Site, Procedure, and Patient Surgery applies to surgical safety checklists and is not relevant to this medical admission scenario. 2
Critical Context: Why This Communication Failure is Life-Threatening
Patients with concurrent asthma and peanut allergy face compounded risk of fatal anaphylaxis, making this communication failure particularly dangerous. 1 The combination of these two conditions represents the strongest risk factors for fatal food-induced anaphylaxis, as peanuts cause the majority of fatalities from food-induced anaphylaxis. 4, 1
Immediate Risks from This Communication Breakdown
Delayed epinephrine administration has been implicated in contributing to fatalities from anaphylaxis, often because allergy information was not effectively communicated to responding providers. 1
Medication errors involving peanut-derived excipients or cross-contaminated pharmaceuticals can occur when allergy information is not communicated. 1
Dietary services may inadvertently provide peanut-containing foods without strict avoidance orders. 1
Biphasic reactions occur in 1-20% of anaphylaxis cases, requiring 4-6 hours of observation, but providers unaware of the allergy may miss early warning signs. 4, 1
What Should Have Been Communicated During Handover
The following allergy information must be communicated during every handover: specific allergen identification (peanut), cross-reactivity risks, emergency medication availability (two epinephrine autoinjectors), asthma control status, and documentation of previous reaction severity. 1
Common Pitfall in This Scenario
The most dangerous pitfall is assuming that patient identification alone ensures safety. 2 While correct patient identification (Goal 1) is essential, it does not guarantee that critical clinical information like allergies is effectively communicated between care teams during transitions of care. 1, 3 This case exemplifies why structured handover communication protocols are essential patient safety interventions.