Incorrect allergy injections: Allergists' experiences and recommendations for prevention

Abstract

There are several reports of fatalities caused by allergen immunotherapy and skin testing. Patients have been reported who have received incorrect allergy injections. These could put them at risk for anaphylactic reaction and a possible fatality. We performed a survey to determine allergists' experiences with incorrect injections and to identify opportunities for prevention. This study was endorsed by the American Academy of Allergy, Asthma and Immunology and the Joint Council of Allergy, Asthma and Immunology. We conducted an e-mail survey of 1717 allergists, asking whether they knew of an incorrect injection administered within the last 5 years in their offices. An incorrect injection is an injection given to the wrong patient or a correct patient receiving an injection of an incorrect dose. Fifty-eight percent of responders reported an event in which a patient had received an injection meant for another patient. Seventy-four percent of responders reported that patients had received an incorrect amount of vaccine. The effect on patients ranged from local reactions to one fatality. Specific reasons given for the incorrect injections were patient name similar to that of another patient with incorrect name check and nurse error resulting in an incorrect dose. We conclude that allergy injections are a potential safety concern. There are a variety of prevention strategies that could be implemented to reduce or eliminate this risk, such as improved nurse training in the administration of allergy injections and compliance with the recommendations in the "Allergen Immunotherapy: A Practice Parameter" for use of patient-specific vials, standardized dosage sheets, and implementation of triple-checking of identity to make sure the correct patient is receiving the correct injection.