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药物过敏标签翻译有误:从患者到病历再到患者。

Drug Allergy Labels Lost in Translation: From Patient to Charts and Backwards.

机构信息

Department of Allergy/Immunology/Rheumatology, Rochester Regional Health, Rochester, NY; Department of Allergy/Immunology/Rheumatology, University of Rochester, Rochester, NY.

Allergy Department, Kaiser Permanente Southern California, San Diego, Calif.

出版信息

J Allergy Clin Immunol Pract. 2021 Aug;9(8):3015-3020. doi: 10.1016/j.jaip.2021.02.005. Epub 2021 Feb 16.

Abstract

The current method of defining, reporting, assessment, labeling, delabeling, and reconciliation of adverse drug reactions (ADRs), and specifically immunologically mediated drug hypersensitivity reactions (HSRs), in electronic health records (EHRs) is inadequate and compromises care quality and safety. It is critical to accurately and succinctly report the signs and symptoms associated with ADRs and suspected HSRs to enable clinicians to determine the plausible reaction type and help guide appropriate future management plans. Despite the current limitations of the EHR allergy module, we must encourage improved clinical documentation and demand technological improvements. Telehealth methods have been shown to be valuable in the assessment of ADRs and HSRs, particularly in the case of penicillin allergy evaluation and delabeling. The implementation, assessment, and refinement of advanced technologies, including clinical informatics and artificial intelligence, along with continued education of health care providers have potential to improve EHR documentation and communication, thereby advancing patient safety efforts.

摘要

当前在电子健康记录(EHR)中定义、报告、评估、标记、去标记和协调药物不良反应(ADR),特别是免疫介导的药物超敏反应(HSR)的方法是不充分的,会影响医疗质量和安全。准确简洁地报告与 ADR 和疑似 HSR 相关的体征和症状至关重要,这有助于临床医生确定可能的反应类型,并有助于指导适当的未来管理计划。尽管目前 EHR 过敏模块存在局限性,但我们必须鼓励改进临床文档记录并要求技术改进。已经证明远程医疗方法在评估 ADR 和 HSR 方面具有价值,特别是在青霉素过敏评估和去标记方面。临床信息学和人工智能等先进技术的实施、评估和改进,以及医疗保健提供者的持续教育,有可能改善 EHR 文档记录和沟通,从而推进患者安全工作。

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