Patient allergies and electronic health records

Summary

This case study written by Matthew Doyle and published by PSNet, Agency for Healthcare Research and Quality, describes a case of a patient in the US who was given a drug they were allergic to, the implications of this and how to mitigate future events.

Content

Key take home messages

• A patient's drug allergy status should be checked and updated at all patient contacts with healthcare professionals.
• Recording suspected drug allergy in the patient record requires a minimum degree of detail including the reaction, the drug given, the time-frame of the reaction from initiation of the drug, and what drugs or drug groups to avoid.
• Both adverse drug reactions and drug allergies should be documented in the electronic patient record, separately if possible but together if not, and should not be removed from the record without consideration of and the involvement from the patient in the decision to remove it.
• Drug allergy status should be recorded on all written communication regarding the patient between health care professionals.