Introduction of 'Anaphylaxis Packs' to improve patient safety in a hospital setting

Abstract

Three reported episodes of anaphylaxis, where 1:1000 adrenaline was not immediately obtainable, triggered us to assess its availability on all adult wards. We found adrenaline was unavailable on 50% of audited wards. A questionnaire for doctors and nurses revealed lack of knowledge on both the management of anaphylaxis and location of emergency drugs. Given that anaphylaxis is a treatable but potentially fatal condition, we held a meeting to discuss the situation with senior pharmacists, resuscitation managers, and senior doctors. Our intervention was to advise the production of 'anaphylaxis packs' as part of the crash trolley kit. This was to be added to the laminated crash trolley check list and to include adrenaline, chlorphenamine, hydrocortisone, and the anaphylaxis algorithm. The aim was to improve ward stock, staff knowledge, and create a consistent location for emergency drugs, so minimising human error, and patient harm. With a PDSA approach we trialled the intervention on four pilot wards. The packs have now been dispersed trust-wide. Re-audit at four months showed 100% ward stock of anaphylaxis packs, more consistent drug location and improved staff knowledge. There were 17 coded incidents of anaphylaxis at this hospital in 2011, the actual figure likely being higher. We feel our project has greatly improved patient safety in this area.