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首页> 外文期刊>The Journal of pharmacy technology: jPT : official publication of the Association of Pharmacy Technicians >Discrepancies Between Patient Self-Reported and Electronic Health Record Documentation of Medication Allergies and Adverse Reactions in the Acute Care Setting: Room for Improvement
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Discrepancies Between Patient Self-Reported and Electronic Health Record Documentation of Medication Allergies and Adverse Reactions in the Acute Care Setting: Room for Improvement

机译：患者自我报告的患者和电子健康记录文献的差异，急性护理环境中的药物过敏和不良反应：改善室

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Background: Allergy information is commonly transcribed into an electronic health record (EHR) for all patients admitted to acute care hospital units by a licensed health care professional. The allergy history is utilized each time a new inpatient medication is prescribed to identify the patient's risk of having an allergic reaction and/or anaphylaxis. There is potential for negative consequences in cases where the allergy history is incorrectly documented. Objective: The objective of this study was to assess the discordance between documented allergy information in the EHR and verbally reported allergy information from a patient interview. Methods: Prospective, observational, nonrandomized study performed within a 2-month period during the Spring of 2016. The study was performed at a teaching community hospital in Chicago, Illinois. A total of 270 patients were interviewed on the general medicine (n = 216) and headache (n = 54) units regarding their medication allergies and reactions. The outcomes were discordance among EHR-documented and verbally stated medication allergies and reactions. Results: The agreement across all medications and reactions between the EHR and patient self-reported interview was 80.9%. There were 31 reactions (6.7%) that were verbally reported by patients but were not documented in the EHR (omissions) and 57 reactions (12.4%) that were verbally reported but were incorrectly documented in the EHR (incorrect documentations). Only 20 out of the 264 verbally reported reactions (7.5%) met the study definition of anaphylaxis. The highest rate of incorrect documentations occurred with opiate agonists, and the highest rate of omissions occurred with anticonvulsants. EHR documentation was more likely to be incorrect among patients who reported gastrointestinal reactions and was more likely to be correct among patients who reported cutaneous reactions. Conclusion: There was a high rate of discordance amid EHR-documented and verbally stated medication allergies and reactions. Errors among opiate agonists, anticonvulsants, and sulfa drugs were most prevalent.
机译：背景：过敏信息通常通过持牌医疗保健专业人员承认急性护理医院单位的所有患者转录为电子健康记录（EHR）。每次规定新的住院治疗以确定患者具有过敏反应和/或过敏性的风险时，每次使用过敏历史。在对过敏历史记录不正确的情况下，存在负面后果。目的：本研究的目的是评估EHR中记录过的过敏信息与患者面试中的口头报告过的过敏信息之间的嫌疑。方法：预期，观察，非扫描研究在2016年春季的2个月内进行。该研究在伊利诺伊州芝加哥的教学界医院进行。在一般医学（n = 216）和头痛（n = 54）单位上，共有270名患者对其药物过敏和反应进行了访谈。 EHR记录的和口头陈述药物过敏和反应中的任何结果都是不安的。结果：EHR与患者之间的所有药物和反应的协议是80.9％。患者的口头报告了31种反应（6.7％），但没有记录在EHR（遗漏）和57个反应（12.4％）中的口头报告，但在EHR中被记录错误（不正确的文件）。在264个口头报告的反应中只有20个（7.5％）达到过敏反应的研究定义。阿片激动剂发生了最高的错误文件率，并且抗抑郁症发生的遗漏率最高。在报告胃肠道反应的患者中，EHR文件更容易在患有胃肠道反应的患者中不正确，并且在报告皮肤反应的患者中更可能是正确的。结论：ehr文件和口头上述药物过敏和反应中存在高度的不障引力。阿片激动剂，抗惊厥药和磺胺类药物中的误差最为普遍。

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