Three nurses wrote it down. No single note shows the danger.
Each shift read only its own notes. The allergy was on Wednesday's page, the missing allergy band on Thursday's, and the swapped antibiotic on Thursday night's.
- Wednesday night, N. A.O“ALLERGY: PCN - anaphylaxis 2019. red allergy band on R wrist.”21:30, line 4
- Thursday day, N. C.U“red band cut off R wrist for resite, not replaced yet.”10:00, line 3
- Thursday night, N. B.K“B6 Augmentin 1.2g IV given.”02:35, line 12
Augmentin is a penicillin. Relayd joins the three notes through the patient and the drug family, then flags bed 6 before the morning ward round.