Medication Allergy Documentation in Ambulatory Care: A Case Report of Errors and Missed Opportunities Quantified during the Unique Transition from Paper Records to Electronic Medical Records

摘要

Adverse drug events can occur in the ambulatory clinical setting from errors in medication allergy documentation. This study was conducted to quantify errors in documentation that occur within both paper and electronic medical records (EMR).During a period of transition from paper to EMR, a cross-sectional chart review was conducted in one ambulatory clinic. All patients receiving care on study days were approached for participation. A medication allergy history was obtained from each participant and validated. This medication allergy history was then compared to the medication allergy documented in several areas within the medical records. Eighty-nine patients were recruited. The error rates for nursing notes, the physician dictation, paper, and electronic summary pages were 0%, 14.8%, 11.1% and 15.5%, respectively. Our findings indicate that errors in medication allergy documentation occur frequently and may be increased when summary information is used. Summarized information should not be used clinically prior to validation. Introduction Medical errors are a common source of morbidity and mortality in the modern health care setting. Understanding errors in documentation can lead to improvements in medication management and safer patient care. In particular, adverse drug events are a common clinical problem in both the inpatient and outpatient setting.1 Lesar et al 2 determined that prescription errors related to missed patient allergies were one of the most common reasons for medication-related errors. Additionally, Jones and Como determined that medication errors involving drug allergies were most commonly caused by a lack of awareness by the prescribing physician.3 Pau et al 4 also found that 20% of patients had inaccurate hospital admission histories with regard to medication allergies, while other studies have demonstrated that medication allergy documentation needs significant improvement.5 No study evaluating the accuracy of medication allergy documentation at multiple points in an outpatient encounter and medical record has been described to date. Understanding current practices in documentation could help improve accuracy in the medical record and ultimately patient care and safety. This study was designed to quantify errors in medication allergy documentation that occur across the medical record. The period of transition from paper to EMR records gives unique opportunity to study the accuracy of this information. Both paper records and an EMR were in use during this study. This study compares documentation of allergy history in an outpatient paper record to documentation in a comprehensive electronic medical record (EMR). In addition, this study was designed to document missed opportunities to update the summary records or problem lists in the paper record and the EMR. Methods Study Design and SettingA cross-sectional chart review was conducted in one family practice clinic, a part of the Scott and White Healthcare System. This clinic is also affiliated with the Central Texas Primary Care Research Network (CenTexNet), a primary care practiced-based research network (PBRN) headquartered in Temple, Texas. Scott & White Healthcare System is an integrated health care network consisting of two large referral hospitals, allied health services, home health care services, multiple specialty clinics and primary care clinics. It is the primary clinical teaching site for the Texas A&M Health Science Center College of Medicine. At the time of the study, physicians and staff were transitioning from primary dependence on paper records to the exclusive use of an outpatient EMR. The EMR used in the system is available to all practicing physicians within both the inpatient and outpatient facilities within the system. Dictated hospital and outpatient records are stored and accessed via this EMR. Laboratory, radiology and nursing notes are also available in the EMR. In addition, many clinics have historically kept a paper record in