The Safety Signal: Building a Just Culture in Allergy and Immunology

In this episode, Christine Cho, MD, FAAAAI, discusses analyzing medical errors within the allergy clinic, from incorrect immunotherapy dosing to the systemic risks of penicillin mislabeling. Dr. Cho explains how shifting from a culture of blame to a "just culture" allows practices to transform "near misses" into learning opportunities that create more robust, reliable systems.

Transcript

Rebecca Saff, MD, PhD, FAAAAI 0:11

Hello, and welcome to Conversations in the World of Allergy, the podcast of the American Academy of Allergy, Asthma & Immunology. I'm your host, Rebecca Saff. Allergy and Immunology is a field that's evolving at an incredible pace, and staying current isn't just important, it's essential. This podcast brings you conversations with leading experts to explore the latest advances and challenge how we think about core topics and ultimately help us deliver the best care to our patients. Patient safety isn't about perfection. It's about preparation, transparency, and being ready to learn and evaluate when things don't go as planned. In this episode, we are discussing medical error. What is it, why it happens, and how human and system factors intersect in everyday clinical practice. We'll explore real-world examples and unplack the principles of just culture, how we move from blame to accountability, and how we turn these hard moments into meaningful improvements in our care. Today we welcome Dr. Christine Cho. Dr. Cho is a pediatric allergist at Children's Hospital Colorado and an associate professor at the University of Colorado Medicine with a special interest in food allergy and asthma. She is dedicated to improving quality and promoting safety in the clinical setting. She is an author of a recent module on ensuring patient safety in allergy, asthma, and immunology that is available through the AAAAI. And I hope this episode will make you excited to check it out and learn more. Dr. Cho, thank you so much for taking the time to join us today and welcome to the podcast. Thanks so much, Rebecca. It's so great to be here. I'd like to start by getting to know you a little better. Can you tell us a little bit more about yourself?

Christine Cho, MD, FAAAAI 1:38

Yes, absolutely. I um, as you said, am an associate professor of clinical practice at the University of Colorado Denver, but primarily see patients at Children's Hospital Colorado. And I really, really enjoy um being an allergist. I see mainly allergy patients because the field is intellectually engaging. As you were saying in your intro, uh the field is changing all the time. Um, but I also really enjoy the ability to develop long-term relationships with my patients and families. And in pediatrics in particular, you're not just treating symptoms, you're improving a child's ability to fully participate in school, play, and daily life, which I find really deeply meaningful.

Rebecca Saff, MD, PhD, FAAAAI 2:27

And how did you become interested in quality improvement and safety in particular?

Christine Cho, MD, FAAAAI 2:32

Yeah, I first became interested in safety work as the clinical medical director for our section, and through that enrolled in a few excellent mentored QI leadership programs at the Institute of Health, Quality, Safety and Efficiency, the IHQSE, here at the University of Colorado. Because much of our field involves food challenges, medication administration, allergy labeling, the risk of anaphylaxis, there were clear opportunities to improve systems of care. And I'm drawn to the idea of not only caring for individual patients, but also improving the reliability and safety of care at a systems level.

Rebecca Saff, MD, PhD, FAAAAI 3:14

And what are the most common types of medical error that we see in allergy immunology?

Christine Cho, MD, FAAAAI 3:20

So this is not well characterized specifically in allergy and immunology, but since the practice is primarily ambulatory, most of the common medical errors are medication safety events and diagnostic errors. Medical errors in the ambulatory setting are quite common, affecting 5 to 7% of patients annually, with an estimated one in 66 consultations involving an adverse event. So definitely a huge problem, even in the ambulatory setting, even though I think in the inpatient setting and in surgical setting, it definitely gets more gets more attention. As far as in our field, uh I think most of the errors are also medication safety events, dosing errors with immunotherapy, biologics, in the food and and drug challenge setting. And definitely I think a huge problem is inaccurate documentation of allergies and the electronic health care record as well.

Rebecca Saff, MD, PhD, FAAAAI 4:35

So in the patient safety world, they kind of take these different types of patient of patient safety errors and they divide them up. Can you walk us through what an adverse event is, a near miss, and a medical error and kind of how they're different?

Christine Cho, MD, FAAAAI 4:48

Yeah, absolutely. These three terms are often used interchangeably, I think, in the clinical setting. And it's really important to understand how they differ because that is really important, kind of trying to figure out how we can learn and improve from them. So a medical error is an act that exposes patients to a potentially hazardous situation. It is about the process, and it can result in either a near miss or an adverse event. Errors can happen from human error or from at-risk behaviors. An adverse event, and this is not in the research setting, is harm to a patient that results from medical care rather than the underlying disease. Not all adverse events involve errors. Some are known, unavoidable risks, but when harm results from an error, it becomes a preventable adverse event. And that is where we need to focus our safety efforts. A near miss is an error that was caught before it reached the patient, or a situation where no harm occurred but easily could have. Near misses should be examined as they can signal a hidden underlying system or organizational weakness that allowed the near miss to happen.

Rebecca Saff, MD, PhD, FAAAAI 6:14

So I'd like to think about some examples to give us, uh put these into context. For example, a patient receives the wrong dose of immunotherapy. What is the best way to so this would be an error? What is the best way to manage this error?

Christine Cho, MD, FAAAAI 6:30

So this is a really, really difficult situation. And so, you know, how I would see this play out in the clinical setting is that probably a nurse or staff member who administered the wrong dose would come and find you and tell you that this happened. The first thing obviously is just to make sure that the patient, if they're having a reaction, is appropriately managed and is safe. Once we can ensure that the patient is doing well, it's very important for the clinician to understand what happened, why it happened, as quickly as possible, because the next step should be to inform the patient that a mistake was made. This can be really, really difficult. And ideally, it's the patient is informed by a clinician who is in a good space because I think you know, when errors happen, understandably, staff members are upset, clinicians are upset, you know, all the people involved. Um, it's a very difficult situation. So it's very, very important to be able to speak with a family in an empathetic and very kind of informative way. So you want to state the facts without blame, um, give an account of what happened, the consequences, and what treatments are being given to correct the error. And then tell the patients that you're still collecting information and that you know, as you become more informed about what happened, um you'll kind of you'll continue to inform them. If there was a really severe reaction with a poor outcome, leadership needs to be notified right away. But if the patient is is doing well, then the error should be reported to whatever reporting system that you have at your practice. And then it also should be documented completely in the chart.

Rebecca Saff, MD, PhD, FAAAAI 8:46

Would you say that so oftentimes the person that's managing the reaction may not be the person's primary physician that they know well? Do you think that having that conversation then is really important? Or do you think that having the person that knows them follow-up or kind of a combination of both?

Christine Cho, MD, FAAAAI 9:03

Um I think it's important for the patient to know right away. Um I think that establishes trust that you're being completely transparent. Um, however, I think it's okay to say at the beginning, this is what happened. Um we don't exactly know why it happened, but we promise, you know, when you're talking to the patient, we promise you that we will launch a full investigation to make sure that this doesn't happen to anybody in the future. And I think it is a good idea for the primary provider who has a relationship with the patient to then reach out afterwards to follow up. But I do think that this needs to be disclosed right away.

Rebecca Saff, MD, PhD, FAAAAI 9:47

So another example. So a nurse catches a biologic that's ordered for the wrong patient, but before it's administered. So the patient isn't necessarily aware there's been no actual error. Why is it important to report this?

Christine Cho, MD, FAAAAI 10:01

Yeah, it's very, very important because the fact that the nurse caught it does not mean the system is safe. You know, it means one person's vigilance compensated for a system failure, and that's not a reliable safety net. Um, these system vulnerabilities will produce the next error, and the next time no one may catch it. And so, with this particular case, we need to know how did the wrong patient's name get on that order? Was it a problem with the electronic health care record? Was it a verbal order that was misheard? Are there two patients with similar names in the clinic session? When near misses are reported and acted upon, um, then staff feel that speaking up leads to change, and that reinforces the reporting culture you need to find errors before they cause harm.

Rebecca Saff, MD, PhD, FAAAAI 11:00

I think that's so important that having staff know that if they report something that people are going to take it very seriously, that it's not a culture of blame, but this is a way we can learn. I think that that really encourages people to notice things and step forward. So we have these better to have a near miss than to actually have an error so we can catch it and not cause harm.

Christine Cho, MD, FAAAAI 11:21

Absolutely. I mean, that is one of the core um components of just culture.

Rebecca Saff, MD, PhD, FAAAAI 11:27

Yeah. So a patient with a mislabeled penicillin allergy avoids first in therapy. This is a problem that we often see. Why is this a patient safety issue? Isn't it better to have it on the list than to not have it on the list?

Christine Cho, MD, FAAAAI 11:40

I mean, I think with our audience, um, you know, we don't we don't really need to um talk too much about, you know, why this is, because most people know, I mean, roughly 10% of the US population carries a penicillin allergy label. We know that less than 10% of those patients are actually allergic, that there are real health consequences of being given alternative antibiotics to the penicillin group, higher rates of adverse effects, increased antimicrobial resistance, driving up health care costs, so all of these things. And it's very, very important to make sure that this is addressed. I always kind of tell the trainees that come through that the allergy list is our domain and that you should not see a patient and have them leave your office without really updating the allergy list and addressing every single drug or food that's on there to make sure that it's really up to date. It's a it's a very, very important safety issue.

Rebecca Saff, MD, PhD, FAAAAI 12:43

Yeah, I think we know so much about penicillin allergy. So all of us are now very aware of kind of the risks of having a penicillin allergy when the patient doesn't actually have the allergy. Um, but we can extrapolate that that all of these things that are listed on the allergy list are gonna mean the patient is not gonna get those as their first line medication if that's what's indicated. And so really verifying that this needs to be there or doesn't need to be there. One of the things that we've done is take all the things like pollen off of the allergy list because it's distracting. And those are not gonna be something that a patient is gonna receive in the hospital that would lead to harm. And so um, we try to eliminate those things that yes, that's an allergy for you, but maybe not, doesn't need to be listed for um when you come in for your colonoscopy.

Christine Cho, MD, FAAAAI 13:28

So yeah, absolutely. We actually talked about this at our quality adherence outcomes committee meeting um at the academy meeting last time, about how just allergy lists are so difficult because just anyone can add anything onto it. And it really provides, I think, more distraction than help in guiding you know, patient care and management.

Rebecca Saff, MD, PhD, FAAAAI 13:56

I know everyone feels very good about adding things to it, and almost no one feels entitled to take it. Exactly. Yeah, which is the problem. So you get these lists of 50 allergies, and you know, half of them actually aren't correct. And so I really love that we are the owners of that list and we really need to make sure it's as accurate as possible to let the patient have the best care wherever they are within the clinical setting.

Christine Cho, MD, FAAAAI 14:20

Yeah, and and also, too, a major problem is that we clear patients of antibiotic allergies, but then they get relabeled. I mean, that's a common problem too. So there's a lot of work that needs to be done in this area.

Rebecca Saff, MD, PhD, FAAAAI 14:35

So one of the things that we need to watch out for is at-risk behaviors. How do at-risk behaviors show up in practice?

Christine Cho, MD, FAAAAI 14:43

Yeah, so at-risk behaviors are the normalized shortcuts and workarounds that individuals don't perceive as risky, but which erode the safety margins built into systems. So they're different from reckless behavior because they're usually well-intentioned. So in allergy practice, drawing up immunotherapy injections ahead of time to save time during a busy clinic, skipping the two nurse verification on a biologic dose because you know it's right, it's always right, allowing a patient to leave after 15 minutes instead of 20 or 30 minutes OBS because they're in a hurry, approving phone in doses without having the chart in front of you, or overriding an allergy alert in the electronic health care record automatically without really kind of thinking about it, because most of the alerts that you receive really aren't a significant risk. And so the danger of at-risk behavior is that it's usually fine right up until it isn't. And repetition without adverse outcome creates false confidence. And so addressing at-risk behavior, it requires coaching and awareness, but not punishment. People need to understand why the behavior is risky and not just be told to stop doing it, because again, they have this false confidence that they've been doing it, it saves time. And so you have to explain why there is an increased safety risk.

Rebecca Saff, MD, PhD, FAAAAI 16:18

I mean, I would argue that uh putting so many alarms on that you get alarm fatigue is probably an at-risk behavior that our systems have adopted that we need to work on as well.

Christine Cho, MD, FAAAAI 16:29

Absolutely. Yeah, I mean, I I think that that is one of the major issues, I think, about when when you're doing this kind of quality improvement and safety work where people say, Oh, well, just add an alert. Well, we get so many alerts that it's really ineffective. And adding one more alert actually makes it more ineffective.

Rebecca Saff, MD, PhD, FAAAAI 16:51

So, what is just culture and how can we use it to improve patient safety?

Christine Cho, MD, FAAAAI 16:58

So, Just Culture is a framework for how organizations and leaders respond to human error and unsafe behavior. It's the foundation of any functioning safety culture. It is non-punitive for errors due to complexity and design, but accountable for reckless or careless behavior of individuals. Um, the core insight of just culture is that we must distinguish between three types of behavior: human error. These are inadvertent mistakes, and they're managed by consolation and system redesign. At-risk behavior, which are shortcuts that we just talked about that individuals don't recognize as risky, but they're managed with coaching and accountability, and then reckless behavior, knowingly ignoring substantial risk, and that warrants punitive or remedial action. Um, so historically, medical culture treated errors and recklessness by blaming and punishing. But then what this created was a culture of silence. People hid mistakes, near misses went unreported, and the same errors continued. Just culture breaks that cycle. When staff trust that honest mistakes will be responded to fairly with curiosity rather than condemnation, they report events. And event reports are our most reliable source of safety data.

Rebecca Saff, MD, PhD, FAAAAI 18:36

So, how do we as clinicians and many of us leaders in our practices respond when an error occurs?

Christine Cho, MD, FAAAAI 18:44

So the first response is always to the patient. Um, you want to ensure that they are safe, provide appropriate clinical care, and offer honest, compassionate disclosure. Patients deserve to know what happened to them. And most medical liability research shows that transparency and apology reduce, not increase litigation risk. But really, I mean that you have to do right by the patient. So they they need to know. And then you investigate the error using just culture principles. For the person involved, if the error was due to human error, the leader should provide psychological support. Um there is profound distress experienced by healthcare workers who are involved in an adverse event. Um, and so they should be given support. Um, I think there is fear, along with kind of the trauma of going through the event, that the healthcare workers will be blamed for this. So it's very, very important that leadership comes out immediately showing support. And then you move to the system analysis. Not who did this, but how did our system allow this to happen? You review the sequence of events, gather information without blame, identify contributing factors. Then you act on what you find and you close the loop with the team. Not only is it important to do the work and to provide an intervention, but it's very, very important to be transparent so that the staff sees that change is being made. Um, and as we talked about, um, that it's worthwhile then to report.

Rebecca Saff, MD, PhD, FAAAAI 20:31

How are checklists or standardized protocols used to reduce error? For example, with immunotherapy administration or in food or drug challenges, how do we use these checklists or using a protocol to reduce error?

Christine Cho, MD, FAAAAI 20:43

Yeah. So reduction of error involves improving efficiency of workflow, ensuring clear communication and creating checks that can help catch errors before they happen. And checklists are not about doubting competent clinicians, they're about acknowledging that human memory and attention are fallible, particularly under conditions of high volume, interruption, and fatigue. It's not just in medicine, but aviation, surgery, procedural medicine have all demonstrated that checklists reduce errors, even among the most experienced practitioners. And so some examples are for subcutaneous immunotherapy, having a pre-injection checklist, kind of confirming the patient identity, that you have the correct vial, the correct dose per the treatment plan, confirmation that EPI is immediately available, and that a post injection protocol should confirm the wait time and patient education about delayed reactions. Similarly, drug and food challenges, having standardized protocols for dosing, observation times, criteria for stopping. A challenge, standardizing treatment. These are all areas where improvisation introduces risk.

Rebecca Saff, MD, PhD, FAAAAI 22:11

I think one of the things that, for example, in challenges that we do that really helps is that before the patient even starts the challenge, all the treatments are written out in terms of weight-based dosing, what we would give, why we would give it. And I think that that really helps in the setting where someone is having a reaction, especially if you're in with a patient and someone needs to respond right away, it's all laid out ahead of time. And so just those small steps, they take a few minutes, but they really make all the difference when there is a problem.

Christine Cho, MD, FAAAAI 22:41

Absolutely. When we started standardizing doses of particular foods, the nurses started color coding a lot of them to just again have another way of bringing attention to what dose, having certain areas where this is the patient, this is a particular patient's area, so that patient's doses and foods don't get mixed. And having standardized dosing, I think really, really helps nursing then feel confident about what dose they're giving one.

Rebecca Saff, MD, PhD, FAAAAI 23:19

Yeah, absolutely. Especially if you have multiple challenges going on, making sure that this area is for this patient, this area is for this patient really reduces any concern that you could be crossing, which one is for which. Exactly. Yeah. What are the highest yield interventions that we can use in allergy immunology to prevent error?

Christine Cho, MD, FAAAAI 23:39

Yeah, absolutely. I think standardization is a big one, as we just talked about. So standardizing food challenges, drug challenge dosing, standardizing immunotherapy preparation and administration workflows. I would strongly recommend that every practice, no matter how small, implement a near-miss reporting system, even a simple paper log or shared document, and that this should be reviewed regularly as a team. I think for busier practices that are able to do this, you could do brief safety huddles at the start of a busy clinic session. Our nursing does that before food challenge. They see their high-risk patients or challenges so that everyone is aware. Certain patients may have more severe reactions. You can standardize allergy documentation, and then also I think designating a safety champion to make sure that these reviews are done is very, very important as well.

Rebecca Saff, MD, PhD, FAAAAI 24:53

So if you don't have as much in terms of resources that maybe a large academic institution has, it sounds like even then it's worth kind of implementing these things, even in the smallest practice, having someone who's in charge of quality and safety and who reviews reactions. Do you think that that's reasonable for a really small private practice?

Christine Cho, MD, FAAAAI 25:14

I I think so. Um, because you know, errors don't just happen in big institutions. They're they're happening everywhere. And if we're not learning from near messes, uh patients suffer. So I think it's really, really important that there is some kind of safety champion that's designated in your institution, institution, no matter how large or small, that this person is going to review reports. Um, and that also leadership is transparent and kind of supporting that work and wanting to promote just culture.

Rebecca Saff, MD, PhD, FAAAAI 25:54

And are there tools available that we can use to identify and track safety events that can help us?

Christine Cho, MD, FAAAAI 26:01

Yeah, I mean, I I think um every large institution certainly has software that where you can file uh events. I did see that there is software available for smaller practices too, if this is something that they would like. I like the software uh because it is easily trackable and there's an opportunity for someone to file an error anonymously. I think that's really, really important to help provide a feeling of safety in reporting. Um, but if you know, I understand that some practices don't have those resources and so really just a log, but I think if people aren't able to file anonymously, then really promoting a just culture is very, very important then in that practice so that people again feel safe to report.

Rebecca Saff, MD, PhD, FAAAAI 26:59

And what can we do to create that culture of safety where people really feel comfortable discussing mistakes? Do you think that as a physician being you know open about how we make mistakes and how we manage them, can that be helpful? Or are there things that we can do to really create that culture?

Christine Cho, MD, FAAAAI 27:19

It starts at the top. It starts with leadership. Yeah. So I think if leaders are open about the mistakes that they have made, their near misses, then it gives everybody else permission to be able to share what they experience. Um if it's the if the culture is only one where trainees and nurses make mistakes, then people will protect themselves by staying silent. The belief that speaking up will not lead to embarrassment or punishment is a single most important prerequisite for a safety culture. Um and so leaders can not only lead by example, but they also can thank people for reporting. They can respond with curiosity rather than defensiveness and then visibly act on what they hear.

Rebecca Saff, MD, PhD, FAAAAI 28:16

And are there communication strategies that are important kind of as we work as a team? So so much of medicine is a teamwork that we can really improve how we manage our day-to-day clinic and reduce our risk.

Christine Cho, MD, FAAAAI 28:29

Yeah, communication failure is a root cause of the majority of sentinel events in healthcare. And so communication tools like SBAR, so that's situation, background assessment recommendation, that creates a shared mental model for clinical communication, particularly handoffs. And that reduces the ambiguity and omission that cause errors. There's also closed loop communication, so when the receiver of an instruction reads it back and then the sender confirms. And so that I think is very important if you have the staff to be able to do that. Um, and so for immunotherapy, for example, um, you have two nurses. One nurse looks at the dosing order, and then the other person draws it up, and then they say, Okay, I'm going to give 0.4 mls from this maintenance file, and then they confirm. That's really important. And then structured handoffs if necessary. We have a really great kind of way to inform and handoffs in our consult service. Uh, and then that is really, really important, making sure that it's not just verbal.

Rebecca Saff, MD, PhD, FAAAAI 29:44

You never know when someone's going to get sick and suddenly someone else to take over at the last minute, and having that written communication, particularly for something like consults, makes so much sense. Absolutely. How do we so we think of redundancy as inefficient, right? We think, okay, we can one person can do that. So, how do we balance efficiency with safety when clinics are so busy and there's so many patients and we're we're trying our best to care for everyone? How do we balance that? Yeah, absolutely.

Christine Cho, MD, FAAAAI 30:11

I mean, the tension's real uh and dismissing it doesn't serve anyone. Allergy practices run high volumes of visits, and efficiency is not optional. Um, it's how you provide access to care. So the most important insight in terms of safety is that safety processes, when done well, are actually very efficient. When you are trying to make something safe, what you should do is try to make the right thing done at the right time the easiest thing to do. So removing all of the barriers and then making all of the other alternatives extremely cumbersome. So that is the whole idea of kind of safety work. Redundancy is important because it does catch near misses, and so that is an important piece of it, but it doesn't need to be cumbersome. And so if you can find ways to try to make the workflow as efficient as possible, those safety checks then will be fast because you've already created the workflow to do the right thing.

Rebecca Saff, MD, PhD, FAAAAI 31:26

No, I think that making that the streamlining so the safest way is the easiest way, is definitely does both hits efficiency and safety at the same time. So one of the things we think about in safety is this idea of a root cause analysis. So something happens and we have to kind of dig deep to figure out what happened, what were the causes in order to hopefully make systems changes so it won't happen again. Can you walk us through how we would do this root cause analysis?

Christine Cho, MD, FAAAAI 31:54

Yeah, absolutely. Before doing that, I wanted to outline the different ways to review errors. So the first way is a case review. This is a multidisciplinary conference presenting the case and spurs discussion of areas of risk using the Just Culture framework. This is what used to be called morbidity and mortality conferences. And those are primarily done at academic institutions. And then an apparent cause analysis, an ACA, is conducted by the safety team, and this is used for events with minimal harm or near misses. It's quick, uses fewer resources than the root cause analysis. The ACA focuses on immediate actions to prevent the event from recurring. And this is the majority of the reviews that are conducted. This is the majority of reviews that are conducted by our safety team, and I think that this is probably what one would do in a smaller practice. But root cause analysis or RCA is a structured, retrospective, deep investigation of a serious adverse event or near miss. The goal is not to assign blame, but to identify the deepest system-level causes that allowed the event to occur. So step one is to gather the facts. You want to reconstruct the sequence of events through chart review, direct interviews with staff. It's very important to conduct these interviews in a non-punitive tone and environmental assessment. And then you create a timeline or flow diagram of the events. The next step is to identify contributing factors. So you ask why repeatedly, we always say in kind of QI safety, the five whys technique until you reach causes rather than approximate ones. So for example, a nurse gave the wrong dose of subcutaneous immunotherapy. Well, why? Well, if the vials were stored adjacent to each other, well, why? There's no standardized storage protocol. Why? Well, no one has ownership of the injection room set up. So then you kind of get to the root cause, and then after that, once you understand the contributing factors, you can categorize them. And the cause-effect diagram, which is also known as the fishbone or the Ishikawa diagram, is a way to organize categories of contributing factors as well. And so domains like communication, training, environment, equipment, policies, patient factors. And that way you can help it can help organize the contributing factors, and then you can develop action items from that. Once you develop action items, you're trying to implement them in terms of kind of hierarchy of effectiveness. And so system redesign and removing barriers is by far the most reliable way to impact and provide change. Standardization is also very important. Checklists, as we talked about, less effective ways are training and education. So, you know, we'll tell staff to be more careful is not an RCA action item. Once you decide on interventions, um then you implement, you measure, it's iterative, and then you also kind of close the loop and make sure that you are communicating to not only the people who are involved, but the entire clinic about um what happened, what was done about it, and how change is being made.

Rebecca Saff, MD, PhD, FAAAAI 36:16

And I'll put in a plug. I think that the module does a great job of walking people through kind of how to think through root cause analysis. And so I that's this is if you're interested in learning more, this is a great chance to go back and go through that module so you can really get to the heart of a root cause analysis. I'd love for you to tell us about an example from your system where you went through this and an improvement came out that really helped to make a medical error into a systems change.

Christine Cho, MD, FAAAAI 36:45

So before we would have the orders of food challenge dosing would be either clicking through buttons or free text. And a lot of the providers would write free text. And so this led to a lot of new or misses where our challenge food challenge director would have to review every single food challenge order to make sure that the dosing was appropriate. And you can imagine, you know, I mean, what happens if our challenge director is sick or you know, I mean, and she would say, she said that 40% of all food challenge orders, she had to make some kind of change. And so we went through all of this and decided that the easiest way to kind of remove barriers was just to create a standardized template that with pre-check doses for all of the commonly allergenic foods that we challenge to. And so if you put in the food, the age of the patient, dosing will automatically populate. And you can add or subtract doses if you want, but that's an extra step. And so we standardize this dosing, so you just click on it, and that has pretty much eliminated all of the dosing errors that we have on the unit. Um, it's created a lot more free time than for our challenge director, who now you know isn't doesn't have to kind of review every single challenge order. It's helped a lot with kind of workflow and throughput. Um, and so that's that's an example.

Rebecca Saff, MD, PhD, FAAAAI 38:37

That's a great example. And you know, making it the easiest way, it pre-populates person, you know, the likelihood someone is going to go in and change that without kind of having an awareness is so low. Absolutely. Well, I think this is great. Thank you so much for all your tips on how we can improve patient safety. Do you have a key takeaway that you really want people to remember? Sure.

Christine Cho, MD, FAAAAI 39:01

I mean, I I just want to say that even the most knowledgeable, compassionate, and dedicated clinicians are not immune to making errors. And those errors have real consequences for patients. And that's why I think it's essential not only to strive for excellence in individual care, but also to understand how to recognize, analyze, and learn from mistakes. Building systems that anticipate human fallibility and prioritize safety is what ultimately makes care more reliable for every patient. And so I think it's really easy for people to say, oh, humans make mistakes, this is okay, don't feel bad, but not really investigate why this happened. And I would just strongly encourage everyone who listens to this podcast who sees patience to think about that the next time an error is made and really to report it. And if you don't have a reporting system to ask leadership to develop one. And then I also want to recognize Brittany Estee, Joyce Shu, Paige Wickner, and Matt Greenhot, the team behind the patient safety module. The level of detail and care that went into it really shows the module preparation took a lot of time, and uh I am really proud of the final product. So thank you to the team for pushing this forward. If quality and safety work interests you, please contact September for me to join the Quality Adherence and Outcomes Committee. This is in the H ETQ interest section. Umotes quality and safety work in our field, and we would love for you to join us.

Rebecca Saff, MD, PhD, FAAAAI 41:00

Yeah. Well, thank you so much and for encouraging us to have open communication and a culture that really encourages communication and working through errors, which we know do happen and how we can make the best care for our patients. Thank you so much, Rebecca. We hope you enjoyed listening to today's episode. Please visit aa aai.org for show notes and any pertinent links from today's conversation. If you like the show, please take a moment to rate and subscribe through wherever you download your podcasts. As a reminder, this podcast is not intended to provide any individual medical advice to our listeners. We do hope that our conversations provide evidence-based information. Any questions pertaining to one's own health should always be discussed with their personal physician. The Find an Allergist search engine on the Academy website is a useful tool to locate a listing of Ford certified allergists in your area. Use of this audio program is subject to the American Academy of Allergy, Asthma & Immunology terms of use degree, which you can find at aa aai.org. Thank you again for listening.