Alexandra E Conway, Chase Rupprecht, Priya Bansal, Irene Yuan, Ziwei Wang, Marcus S Shaker, Marylee Verdi, Joel Bradley
Adverse events occur in all fields of medicine including allergy-immunology, where allergen immunotherapy medical errors can result in significant harm. Though difficult to experience, such errors constitute opportunities for improvement. Identification of system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response is composed of four major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the Plan-Do-Study-Act cycle), and (4) communication and resolution...
March 12, 2024: Annals of Allergy, Asthma & Immunology