Allergy-Related Medication Error Reports Submitted to a Large Patient Safety Reporting System


  • Matthew Grissinger Institute for Safe Medication Practices (ISMP)
  • Michael J Gaunt Institute for Safe Medication Practices (ISMP)
  • Alexander Shilman Institute for Safe Medication Practices (ISMP)



drug allergy, drug reaction, medication errors, medication safety, patient safety


Medication allergies can and do cause patient harm. Managing a patient’s allergies is a challenge for institutions because failures can happen throughout the medication-use process. A total of 854 Medication Error events associated with patient allergies that occurred between July 2016 and June 2018 were reported through a large event reporting database. Analysts categorized these events into the following five stages: obtaining information from the patient, documenting allergies in the record, ordering medications, verifying orders, and administering medications. More than half (56.3%; n = 481) of the events reached the patient. Most likely to reach patients were events involving breakdowns when obtaining information from the patient (74.7%, n = 68 of 91) and administering medications (97.6%, n = 281 of 288). In reports that indicated allergies were properly documented, the majority (87.3%, n = 289 of 331) of the events that reached patients passed through two or more stages. Organizations may use this information to inform proactive efforts to implement system-based strategies to improve the medication-use process.


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How to Cite

Grissinger, M., Gaunt, M. J., & Shilman, A. (2019). Allergy-Related Medication Error Reports Submitted to a Large Patient Safety Reporting System. Patient Safety, 1(1), 18–27.



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