A 67-year-old man is admitted at night to your hospital service for treatment of pneumonia. He has an allergy to cephalosporin antibiotics, which is noted in his medical record. At the time of the interview and examination, you forget to ask him about allergies, and in your efforts to expedite the start of his treatment you do not notice the antibiotic allergy documented in his medical record. You write an order for a cephalosporin antibiotic and a nurse gives the drug to the patient, intravenously.

Outcome #1 (no harm):

The next morning on rounds, you notice his cephalosporin allergy in the medical record. You are relieved to find that the patient has no new complaints and there is no evidence of an allergic reaction. You discontinue the cephalosporin and order an alternative antibiotic. The patient gives no indication that he is aware of any problems in his care. In this scenario, how likely is it that you would tell the patient that you mistakenly ordered, and he received, an antibiotic to which he was known to be allergic?

Outcome #2 (minor harm):

The next morning on rounds, the patient is moderately uncomfortable due to diffuse itching and has a rash all over his body. You discontinue the cephalosporin, order an alternative antibiotic, and the patient recovers fully from the drug reaction over the next 3 days. In this scenario, how likely is it that you would tell the patient that you mistakenly ordered, and he received, an antibiotic to which he was known to be allergic?

Outcome #3 (major harm):

Two hours after you admit the patient to the hospital, you receive a call from the ward nurse. The nurse explains that half an hour after the cephalosporin was administered, the patient was found to be in respiratory distress and then anaphylactic shock. Cardiopulmonary resuscitation was administered and the patient was transferred to the intensive care unit. Subsequent cardiac testing shows that a moderate myocardial infarct has occurred. The patient’s condition stabilizes and he is transferred out of the intensive care unit after 3 days. In this scenario, how likely is it that you would tell the patient (when stable) that you mistakenly ordered, and he received, an antibiotic to which he was known to be allergic and which caused his anaphylactic shock?