Patient Safety is NOT a Bowl of Cherries!

This journey began when St. Francis Hospital gave fruit cocktail to a patient with a severe allergy to cherries noted in one part of her medical record, but not in any other. The patient knew not to eat this. A true sentinel event was prevented, but the root cause analysis team convened and discovered that while the hospital had reviewed other events involving allergies to medication, food, latex, etc., the corrective actions had been too narrow, related to each event discretely, instead of system-wide. A baseline study found that the facility's medical records had six to 18 different places for documentation of allergies. Not one record reviewed had consistent information.