Deas Crystal M, White C Whitney
Samford University, McWhorter School of Pharmacy, Clinical Pharmacist, Cooper Green Mercy Health Services, Birmingham, AL.
University of Mississippi School of Pharmacy, University of Mississippi Medical Center, Jackson, MS.
Innov Pharm. 2018 Oct 24;9(3):1-8. doi: 10.24926/iip.v9i3.1463. eCollection 2018.
Drug allergy documentation in the patient medical record varies in level of detail, and drug intolerances are often inappropriately documented as an allergy in the medical record. A pilot study was conducted to determine the impact of a pharmacy-led drug allergy clarification service.
The pilot quality improvement service was implemented in Fall 2016. General medicine patients were identified through daily census reporting and the electronic medical record (EMR) was reviewed within 72 hours of admission for documented drug allergies and/or intolerances. Patients were interviewed by a clinical pharmacist or a fourth year pharmacy student to determine a complete drug allergy and intolerance history.
A total of 55 patients were interviewed and received the pilot service. A drug allergy/intolerance was documented in EMR for 54.5% (n=30) of patients interviewed. Of those 30 patients, 96.6% (n=29) were noted to have at least one discrepancy between EMR documentation and patient interview. The primary discrepancy noted was drug allergies or intolerances documented in the EMR without a description of the reaction.
A pharmacy-led drug allergy clarification service was effective in identifying and clarifying EMR documentation of patients' drug allergies and intolerances. Patients with incorrect or incomplete allergy documentation may receive alternative therapy, which could increase costs and lead to unwanted adverse effects or less effective treatment. As a result of the pilot study, the program has remained in effect and is being expanded to other units within the institution.
患者病历中的药物过敏记录在详细程度上存在差异,药物不耐受情况在病历中常被不恰当地记录为过敏。开展了一项试点研究以确定由药房主导的药物过敏澄清服务的影响。
2016年秋季实施了试点质量改进服务。通过每日普查报告确定普通内科患者,并在入院72小时内查看电子病历(EMR),以了解记录的药物过敏和/或不耐受情况。由临床药剂师或四年级药学专业学生对患者进行访谈,以确定完整的药物过敏和不耐受病史。
共对55名患者进行了访谈并提供了试点服务。在接受访谈的患者中,54.5%(n = 30)的患者在电子病历中有药物过敏/不耐受记录。在这30名患者中,96.6%(n = 29)的患者在电子病历记录和患者访谈之间存在至少一处差异。主要差异是电子病历中记录了药物过敏或不耐受,但未描述反应。
由药房主导的药物过敏澄清服务有效地识别并澄清了患者药物过敏和不耐受的电子病历记录。过敏记录不正确或不完整的患者可能会接受替代治疗,这可能会增加成本并导致不良副作用或治疗效果不佳。作为试点研究的结果,该项目持续有效并正在扩展到机构内的其他科室。