Improving Allergy Documentation : A Retrospective Electronic Health Record System-Wide Patient Safety Initiative
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved..
OBJECTIVES: Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been reported. The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module.
METHODS: We assessed free-text allergy entries in a commercial EHR used at a multihospital integrated health care system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high-risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list.
RESULTS: We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergies (18%), contrast media allergies (13%), "no known allergy" (12%), drug allergies (2%), and "no contrast allergy" (2%). Most free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in perioperative settings (20%). We remediated a total of 52,206 free-text entries with automated methods and 79,578 free-text entries with manual methods.
CONCLUSIONS: Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent, and safe guidelines for documenting allergies.
| Medienart: |
E-Artikel |
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| Erscheinungsjahr: |
2022 |
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| Erschienen: |
2022 |
| Enthalten in: |
Zur Gesamtaufnahme - volume:18 |
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| Enthalten in: |
Journal of patient safety - 18(2022), 1 vom: 01. Jan., Seite e108-e114 |
| Sprache: |
Englisch |
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| Beteiligte Personen: |
Li, Lily [VerfasserIn] |
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| Links: |
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| Anmerkungen: |
Date Completed 23.02.2022 Date Revised 10.02.2024 published: Print Citation Status MEDLINE |
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| doi: |
10.1097/PTS.0000000000000711 |
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| funding: |
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| Förderinstitution / Projekttitel: |
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| PPN (Katalog-ID): |
NLM310681154 |
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| 500 | |a Date Revised 10.02.2024 | ||
| 500 | |a published: Print | ||
| 500 | |a Citation Status MEDLINE | ||
| 520 | |a Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. | ||
| 520 | |a OBJECTIVES: Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been reported. The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module | ||
| 520 | |a METHODS: We assessed free-text allergy entries in a commercial EHR used at a multihospital integrated health care system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high-risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list | ||
| 520 | |a RESULTS: We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergies (18%), contrast media allergies (13%), "no known allergy" (12%), drug allergies (2%), and "no contrast allergy" (2%). Most free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in perioperative settings (20%). We remediated a total of 52,206 free-text entries with automated methods and 79,578 free-text entries with manual methods | ||
| 520 | |a CONCLUSIONS: Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent, and safe guidelines for documenting allergies | ||
| 650 | 4 | |a Journal Article | |
| 650 | 4 | |a Research Support, Non-U.S. Gov't | |
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| 700 | 1 | |a Hallisey, Robert K |e verfasserin |4 aut | |
| 700 | 1 | |a Hanson, Carol |e verfasserin |4 aut | |
| 700 | 1 | |a McKee, Ashley E |e verfasserin |4 aut | |
| 700 | 1 | |a Zuccotti, Gianna |e verfasserin |4 aut | |
| 700 | 1 | |a Mort, Elizabeth A |e verfasserin |4 aut | |
| 700 | 1 | |a Sequist, Thomas D |e verfasserin |4 aut | |
| 700 | 1 | |a Kaufman, Nathan E |e verfasserin |4 aut | |
| 700 | 1 | |a Seguin, Claire M |e verfasserin |4 aut | |
| 700 | 1 | |a Kachalia, Allen |e verfasserin |4 aut | |
| 700 | 1 | |a Blumenthal, Kimberly G |e verfasserin |4 aut | |
| 700 | 1 | |a Wickner, Paige G |e verfasserin |4 aut | |
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