The seeds of an adverse drug interaction can be planted at any point in the care process, by any of the individuals involved. For instance, take a look at these common scenarios:
- A clinician, overwhelmed by meaningless alerts, overrides a warning and misses crucial information about a patient's drug allergy.
- A physician office's electronic health record (EHR) system enters the correct drug allergy information, but the pharmacist is unaware of the information.
- A young adult patient is allergic to an antibiotic, but doesn't know exactly what happened when he took the antibiotic as a child and he doesn't mention it when being treated for pneumonia.
The chances that any one of these situations may occur is increasing.
Override rates for alerts have been steadily rising, from 50% in the mid-1990s, to almost 90% in 2015. Allergy alerts are an important type of these increasingly overridden alerts. ECRI Institute's Partnership for Health IT Patient Safety convened a workgroup to examine what technology could do to improve capture and communication of drug allergy information.
Access to accurate and up-to-date drug allergy information is a vital component to effective, safe, and timely patient care. Yet, despite the use of technology and its ability to provide many forms of clinical decision support (CDS), such as alerts, adverse events due to drug allergy interactions continue to occur.
Alert overrides can occur because the messaging associated with the alert is unclear or because information is missing. They can also occur because the ingredients, rather than primary drug component, trigger alerts. While evidence suggests the alerts being overridden are often insignificant, the consequences of overriding drug allergy alerts can sometimes be life-threatening.
To ensure this vital information is captured, CDS for drug allergies must be improved. It will take time, but there are safety measures that organizations can take today. Every stakeholder has a role in improving this process: from the patient, who can become better informed about his medical history, to the EHR vendor, who can design systems that ensure alerts are triggered only when they need to be.
Building on a set of core goals, the Partnership's workgroup developed four recommendations:
- Use technology to standardize the documentation of drug allergy status. Standardization can help facilitate CDS and aid in triggering alerts that occur promptly when they are critical and necessary.
- Provide actionable drug allergy alerts to improve the safety and effectiveness of drug allergy communications. Different contexts of alerts should be communicated. Alerts should be tiered so that that they are intrusive only when they need to be. They should be actionable—an alert should trigger when a patient has an allergy to a particular drug, such as Tylenol with Codeine, rather than every time the patient has an order for Tylenol. It is also worthwhile to know whether a patient has taken a drug previously with no problem.
- Use technology to monitor the effectiveness of allergy alerts. In order to improve any system, data must be gathered. In the case of allergy alert systems, this means tracking alert and override rates to learn when and why they occur and to use dashboards to show this information.
- Engage patients through the use of technology to provide accurate drug allergy communications. In order for the system to improve, patients must be active partners in their care. Vendors are already working on developing patient-facing products that can allow individuals to better inform clinicians about their conditions, including allergies, current medications, and patient record inaccuracies. Portals, while useful, still have not been widely embraced. Informed communication between providers and patients is an excellent safeguard and is essential to this process.
What is it going to take? There is no simple fix. Gathering and accurately recording information, with an ability to trigger a reminder or an alert when needed, will positively impact safer care. It is a start.
Clinicians, patients, families, caregivers, and those that design and provide technology solutions must continue to work together to improve safe communication of drug allergy information. Otherwise, drug allergy events will continue, with potentially devastating consequences.
To learn more about our drug allergy interaction recommendations, and to download our implementation strategies and drug allergy toolkit, visit our Safe Health IT Practices website or listen to our podcast. Additional resources are available from ECRI Institute’s The Partnership for Health IT Patient Safety.