Leveraging learning systems to improve quality and patient safety in allergen immunotherapy.

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying 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 comprises 4 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. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.
Competing Interests: Disclosures Dr Bansal serves on the board of directors of the American Academy of Allergy, Asthma and Immunology and American Board of Allergy and Immunology (views expressed are her own). She has participated in advisory boards and served as a speaker for ALK, AstraZeneca, Bryn, Sanofi Genzyme/Regeneron, Takeda, CSL, Pharming, and Glaxo Smith Kline. Dr Shaker is a member and cochair of the Joint Task Force on Practice Parameters, serves on the editorial board of The Journal of Allergy and Clinical Immunology In Practice, is an associate editor of Annals of Allergy, Asthma & Immunology, serves on the board of directors of the American Academy of Allergy, Asthma, and Immunology (views expressed are his own), and has participated in research that has received funding from DBV. Dr Bradley is the director of Graduate Medical Education Quality and Safety, Dartmouth Health. The remaining authors have no conflicts of interest to report.
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