Design:  A process map of allergen immunotherapy administration at our institution was constructed. Errors in allergen immunotherapy were identified and analyzed in the context of the process map.

The main findings were the following:  Allergen administration dosing errors were low in our practice, ranging from 0.06% to 0.1%. The most frequent error types occurred when a patient had an atypical dosing schedule (diverged from standard protocol) and when bottles

The impact on practice was the following;  The 2 most frequent error types were addressed by changing the labeling system for those on atypical doses and by simplifying dosing protocols when bottles change.