Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.
Li L, Foer D, Hallisey RK, et al. Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative. J Patient Saf. 2022;18(1):e108-e114. doi:10.1097/pts.0000000000000711.
Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).