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A novel schema to classify allergy-related safety events in healthcare

Published: April 7, 2022

Given that at least 10% of American adults have a food allergy and that adverse drug reactions occur in 10-15% of hospital admissions, our health systems must work to optimize the safety of the over 7 million annual interactions that patients with allergies have with the healthcare system. Doing so requires multiple operational processes to be optimized, both on their own and in their interactions with other processes. Despite the importance of allergy safety in healthcare settings, there is no schema to facilitate tracking and promotion of allergy safety.

Phadke et al. in this study published in The Journal of Allergy and Clinical Immunology: In Practice aimed to identify, measure, and classify the safety failures that led to allergy-related safety events. The team searched voluntary safety reports across 2 academic medical centers over 5 years using a keyword search algorithm to identify potential allergy-related safety events. A coding group of allergists/immunologists, biomedical informaticians, and quality and safety experts manually reviewed these events to confirm which ones were allergy-related safety events and then used these events to create a classification schema integrating both human and electronic health record (EHR) factors.

From 299,031 safety reports, 1,922 (0.6%) reports were identified by the keyword search algorithm to potentially contain an allergy safety event; 744 (0.2%) reports were confirmed as allergy safety events by manual review. Allergy safety events were coded using the newly developed classification schema, which included 5 primary categories with 22 subcategories. The 1st primary category was incomplete/inaccurate EHR documentation (n=375, 50.4%), including entering/updating allergies in the allergy module; inadequately obtaining, confirming, and recording allergy history; administration of medications without EHR orders; free-text allergy entries; and failure to adequately confirm patient identity during the patient care process. The 2nd primary category was human factors (n=175, 23.5%), including inadequate intra- and inter-team communication, overridden allergy alerts, and inadequate personnel training. The 3rd primary category was allergy alert limitation and/or malfunction (n=127, 17.1%), including absence of allergy alerts for kit contents and devices, absence of allergy alerts for minor ingredients, alerts that the receiving user could not act upon, inadequate alert/problem list synchronization, absence of alerts for orders that were active before the allergy was entered, inappropriate allergy alerts firing, and appropriate allergy alerts not firing. The 4th primary category was data exchange and interoperability failures (n=91, 12.2%), including inadequate interdepartmental EHR-to-EHR communication within a hospital, inadequate care pathway EHR-to-EHR communication, inadequate EHR-to-EHR communication at time of transition between EHR systems, and inadequate EHR communication between EHR systems at different hospitals within a healthcare system. The final primary category was EHR system default options (n=30, 4.0%), including inappropriate alert filtering based on user settings, inadequate allergy dictionary defaults, and inadequate medication dictionary defaults. Drugs (n=537, 72.1%), especially antibiotics and diagnostic contrast agents, were the most common culprit, but latex, food allergens, and adhesives were also common culprits.  Over 1/3rd (733 events, 38.2%) of events caused some degree of patient harm.  

This safety failure categorization will serve as the initial step toward reducing allergy safety events in healthcare settings and ideally form the foundation of an allergy safety failure taxonomy approved by international consensus. This path will necessitate a focus on both human and electronic health record factors and the interaction between them to promote allergy-related patient safety.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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