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MDT meeting to discuss patient case. Patient is 26 year old female with pneumonia. Decided to commence antibiotics.
BYPASSES HARD-STOP Overrides computer warning of patient allergy (in a hurry, used to seeing unnecessary warnings on Rx system).
Dr Phoebe prescribes course of ampicillin (IV infusion).
Cat the pharmacist receives Rx and assumes Dr has prescribed with knowledge of allergy severity (unknown clinical reason).
Nurse Rowe administers ampicillin without checking patient's allergy wristband or hospital chart.
Nurse Rowe is distracted by Gobind the porter. He ignores the patient's concerns about penicillin.
Rhys administers adrenaline .
Physiotherapist Rhys discovers patient in anaphylactic shock.
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