Improving Allergy Documentation: A Retrospective Electronic Health Record System–Wide Patient Safety Initiative

OBJECTIVESDocumentation 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 en...

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Bibliographic Details
Published in:	Journal of patient safety Vol. 18; no. 1; pp. e108 - e114
Main Authors:	Li, Lily, Foer, Dinah, Hallisey, Robert K., Hanson, Carol, McKee, Ashley E., Zuccotti, Gianna, Mort, Elizabeth A., Sequist, Thomas D., Kaufman, Nathan E., Seguin, Claire M., Kachalia, Allen, Blumenthal, Kimberly G., Wickner, Paige G.
Format:	Journal Article
Language:	English
Published:	United States Lippincott Williams & Wilkins 01-01-2022 Copyright Wolters Kluwer Health, Inc. All rights reserved
Subjects:	Documentation Drug Hypersensitivity - prevention & control Electronic Health Records Humans Patient Safety Retrospective Studies
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Summary:	OBJECTIVESDocumentation 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. METHODSWe 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. RESULTSWe 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. CONCLUSIONSThrough 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.
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ISSN:	1549-8417 1549-8425
DOI:	10.1097/PTS.0000000000000711