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Background

Medication errors are a frequent problem in the accident and emergency (A&E) department.

Case description

A 17-year-old boy was referred to our A&E department with an anaphylactic reaction to peanuts. Because of various shortcomings in the care process in A&E, adrenaline was administered intravenously instead of intramuscularly, resulting in a broad complex tachycardia. We analysed these shortcomings using the ‘Prevention and recovery information system for monitoring and analysis’ (PRISMA) method.

Conclusion

Medication errors are usually a result of shortcomings in non-technical skills, such as communication and situational awareness. Training these skills by applying the concept ‘Crew resource management’ may reduce medication errors and improve patient safety.

Conflict of interest and financial support: none declared.