Which International Patient Safety Goal addresses miscommunication in a child who had an acute asthma exacerbation during handoff and was later found to have a peanut allergy?

International Patient Safety Goal: Decrease Mistakes Due to Miscommunication

The correct answer is C: Decrease mistakes due to miscommunication. This case directly exemplifies a communication failure during handover where critical allergy information was not effectively transmitted, placing the child at risk for fatal anaphylaxis from inadvertent peanut exposure during acute asthma management 1, 2.

Why This is a Communication Safety Issue

The handover period represents the most dangerous communication transition in healthcare where critical allergy information must be accurately transmitted 1, 2. In this scenario:

• The peanut allergy was discovered by the nurse during handover, indicating it was not properly communicated by the transferring team 1
• Children with concurrent asthma and peanut allergy face compounded risk for fatal food-induced anaphylaxis, as asthma is the strongest risk factor for fatal food-induced anaphylaxis 1, 2
• Poor communication contributes to 24.0% of patient safety incidents (IQR 12.0% to 46.8%), and when it is the sole cause, accounts for 13.2% of incidents 3
• Communication failures are a major cause of medical errors, though not necessarily the majority as commonly claimed 4, 3

Critical Communication Elements That Failed

The following allergy information must be communicated during every handover 2:

• Specific allergen identification (peanut allergy was not communicated) 2
• Emergency medication availability (epinephrine autoinjector location) 1
• Asthma control status (particularly critical given the acute exacerbation) 1
• Previous reaction severity (to assess anaphylaxis risk) 1

Immediate Actions Required After Discovery

Upon discovering the peanut allergy during handover, the provider must 2:

• Document allergy prominently in all systems with clear visual alerts 2
• Verify two epinephrine autoinjectors are immediately accessible 1, 2
• Review all current medications for peanut-derived ingredients or cross-contamination risk 2
• Communicate to dietary services with strict avoidance orders and cross-contamination precautions 2
• Optimize asthma control, as respiratory symptoms may mask early anaphylaxis 1, 2

Why the Other Options Are Incorrect

Option A (Preoperative Surgical Checklist) is not applicable because this case involves medical management of acute asthma, not a surgical procedure 1.

Option B (Identify patient correctly by using two identifiers) addresses patient identification errors, not communication failures about known allergies during handover 1. The patient's identity was not in question—the problem was that critical allergy information was not transmitted 1, 2.

Common Pitfalls in Allergy Communication

• Never assume allergy information has been communicated during handover—always verify directly 1
• Asthma exacerbation itself can mask early anaphylaxis symptoms, delaying recognition and treatment 2
• Delayed epinephrine administration has been implicated in contributing to fatalities from anaphylaxis, often because allergy information was not effectively communicated 2
• Oral tingling or mild symptoms can rapidly progress to life-threatening anaphylaxis within minutes 2
• Biphasic reactions occur in 1-20% of cases, requiring 4-6 hours observation even after initial symptom resolution 2

Documentation Standards to Prevent Future Errors

Allergy documentation must include 2:

• Specific allergen name (peanut, not just "nuts") 2
• Reaction type and severity (urticaria, anaphylaxis, etc.) 2
• Time course (immediate vs. delayed) 2
• Confirmatory testing results if available 2