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A 7-year-old boy was admitted to a pediatric surgical unit to have an inguinal hernia repaired. When the nurse took the boy's history from his mother, she learned he was allergic to penicillin. The nurse noted this allergy on the boy's admission sheet, medication administration record, Kardex file, and her nurses' notes. She also placed an allergy alert sticker on the boy's bedside medication sheet. But she forgot to place one on the front of his chart at the nurses' station.
Later, a medical student examined the boy and also took his history. He knew the nurse had taken a history, so he checked the front of the patient chart at the desk to see if it had any warning stickers. Seeing none, he charted "no known allergies" on the patient's medical history. The intern and anesthesiologist, who also examined the patient, saw the student's note and consequently charted "no known allergies" on their respective evaluation sheets.
After surgery, the patient's doctor wrote an order for penicillin G, 1 million units, to be given intramuscularly. Seeing no warnings on front of the patient's chart, the recovery room nurse administered the penicillin.
Within a short time, the patient developed bronchospasm. He was given epinephrine and observed for several hours, then returned to the pediatric unit. No one on either unit related the bronchospasm to the penicillin.
The doctor then wrote a follow-up order for a dose of oral penicillin. The medication nurse checked the bedside medication sheet before giving the dose and was surprised to see the penicillin allergy warning. She notified the patient's doctor, who cancelled the penicillin order.
The nurse then put a warning sticker on the front of the patient's chart and told the rest of the staff what had happened. They realized that the bronchospasm must have been a reaction to the penicillin given in the recovery room.
The chain of events in this error began when the admitting nurse neglected to place a warning sticker on the front of the patient's chart. The medical student compounded the error by relying on the absence of such a sticker for his data on the patient's allergies. The recovery room nurse also relied on the absence of a warning sticker for her information.
Unfortunately, many people do rely on warning stickers (or lack of them) for allergy information. But these stickers were never meant to be the last word on a patient's allergies ... the information in the chart is.
So to prevent such an error, always document allergy information in and on the patient's chart, following hospital policies and procedures. Before administering a drug, check for allergies in the chart, and ask the patient (or a family member) if he's allergic to any drug.
This last check is important when administering all drugs, but especially when you're giving penicillin, which causes more allergic reactions than any other medication.