Allergy Alerts Research Articles

Clinical Decision Support Systems for Drug Allergy Checking: Systematic Review.

BackgroundWorldwide, the burden of allergies—in particular, drug allergies—is growing. In the process of prescribing, dispensing, or administering a drug, a medication error may occur and can have adverse consequences; for example, a drug may be given to a patient with a documented allergy to that particular drug. Computerized physician order entry (CPOE) systems with built-in clinical decision support systems (CDSS) have the potential to prevent such medication errors and adverse events.ObjectiveThe aim of this review is to provide a comprehensive overview regarding all aspects of CDSS for drug allergy, including documenting, coding, rule bases, alerts and alert fatigue, and outcome evaluation.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as much as possible and searches were conducted in 5 databases using CPOE, CDSS, alerts, and allergic or allergy as keywords. Bias could not be evaluated according to PRISMA guidelines due to the heterogeneity of study types included in the review.ResultsOf the 3160 articles considered, 60 met the inclusion criteria. A further 9 articles were added based on expert opinion, resulting in a total of 69 articles. An interrater agreement of 90.9% with a reliability Κ=.787 (95% CI 0.686-0.888) was reached. Large heterogeneity across study objectives, study designs, study populations, and reported results was found. Several key findings were identified. Evidence of the usefulness of clinical decision support for drug allergies has been documented. Nevertheless, there are some important problems associated with their use. Accurate and structured documenting of information on drug allergies in electronic health records (EHRs) is difficult, as it is often not clear to healthcare providers how and where to document drug allergies. Besides the underreporting of drug allergies, outdated or inaccurate drug allergy information in EHRs poses an important problem. Research on the use of coding terminologies for documenting drug allergies is sparse. There is no generally accepted standard terminology for structured documentation of allergy information. The final key finding is the consistently reported low specificity of drug allergy alerts. Current systems have high alert override rates of up to 90%, leading to alert fatigue. Important challenges remain for increasing the specificity of drug allergy alerts. We found only one study specifically reporting outcomes related to CDSS for drug allergies. It showed that adverse drug events resulting from overridden drug allergy alerts do not occur frequently.ConclusionsAccurate and comprehensive recording of drug allergies is required for good use of CDSS for drug allergy screening. We found considerable variation in the way drug allergy are recorded in EHRs. It remains difficult to reduce drug allergy alert overload while maintaining patient safety as the highest priority. Future research should focus on improving alert specificity, thereby reducing override rates and alert fatigue. Also, the effect on patient outcomes and cost-effectiveness should be evaluated.

Allergy Alert Test for p-Phenylenediamine-Allergic Hair Dye Users.

Contact dermatitis to hair dyes remains a health concern. Regulations in many countries require consumer self-testing for hair dyes, but no standardized procedure exists. The aim of this study was to develop a self-test protocol for an allergy alert test (AAT) that can elicit a self-noticeable alert signal in p-phenylenediamine (PPD)-allergic consumers. Simulating consumer use conditions (open application for 45 minutes after mixing with a developer), PPD-positive hair dye-allergic subjects and PPD-negative control subjects were tested on the forearm and behind the ear with experimental products containing 0.05%, 0.25%, 0.75%, and 2% PPD. Reactions were self-evaluated by subjects and independently assessed by dermatologists. The AAT caused a reaction self-noticeable on the forearm in 90.5% (38/42) and behind the ear in 93% (39/42) of the PPD-positive subjects. This was objectified by a dermatological evaluation. The strength of the AAT response and the number of responding subjects increased with increasing PPD concentrations. Allergy alert test responses were also dependent on the reaction strength of the diagnostic patch test to PPD before the study; in subjects with (+++) patch test reactions, 19 of 19 were positive. All 48 control subjects were negative to the AAT. Therefore, the AAT protocol provides a signal indicative of an allergic reaction in PPD-allergic hair dye consumers.

Exploring what motivates and sustains support group engagement amongst young people with allergies: A qualitative study.

Positive self-care behaviours are more likely in young people who engage with allergy support groups, but reasons for this association are not well understood. This study explored how and why young people engage with allergy support groups to identify what activities and resources are beneficial. In-depth, semistructured interviews were conducted with young people aged 12-21years who reported engaging with allergy support groups (in person or online). Interviews were audiotaped, transcribed verbatim and analysed using thematic content analysis. The 21 participants had a range of allergies; initially, most joined support groups on suggestion of their parent/carer although older participants sought groups independently. Feeling included and sharing experiences with people with similar problems/challenges were highly valued. Through membership, young people reported improved self-esteem and confidence in both managing their allergies and lives generally. Information, such as allergy alerts and hard-hitting video campaigns, were reported to positively influence adherence to self-care behaviours such as carrying medication. Participants wanted greater availability of allergy support groups, and higher profiles in health care and educational settings, as well as through social media. Participants valued the psychological and practical support of networking with others with allergies, and described how membership improved their confidence. This study also provides insight into the ways support groups improve young people's adherence to medical advice and positive self-care behaviours; participants responded well to hard-hitting video campaigns which appeared to emphasize the severity and susceptibility of anaphylaxis. Participants identified the need for more active promotion of support groups amongst young people and their clinicians, as well as making them available in more localities.

Evaluation of 'Definite' Anaphylaxis Drug Allergy Alert Overrides in Inpatient and Outpatient Settings.

Drug-allergy interaction (DAI) alerts are generated when a known adverse sensitivity-inducing substance is prescribed. A recent study at our institution showed that providers overrode most DAI alerts, including those that warned against potentially life-threatening 'anaphylaxis'. The aim of this study was to determine the rate of anaphylaxis overrides, the reasons for these overrides, whether the overrides were appropriate, and if harm occurred from overrides. All DAI alerts, with a reaction of 'anaphylaxis', were analysed for inpatients and outpatients within our health system between January 2009 and December 2011. Only alerts that were triggered by 'definite' alerts (i.e. same ordered medication as documented allergen) were included. Patient charts were reviewed to assess the appropriateness of overrides and potential harm, according to a predetermined set of criteria. A total of 202 inpatient and 16 outpatient alerts met the inclusion criteria. The rate of overrides for 'definite' anaphylaxis DAI alerts was high (inpatient: n=93, 46.0%; outpatient: n=11, 68.8%) but appropriate for most overrides in the inpatient (n=78, 83.9%) and outpatient settings (n=11, 100%). The most common override reasons in the inpatient and outpatient settings were 'administer per desensitization protocol' (n=64, 31.7%) and 'patient does not have this allergy' (n=7, 63.6%), respectively. No harm was associated with overrides in either setting, particularly because many medications were not administered. Overrides of 'definite' anaphylaxis DAI alerts were common and often appropriate. Most overrides were due to desensitizations. Allergy reconciliation for patients could further improve critical decision support.

Medication-related clinical decision support alert overrides in inpatients.

To define the types and numbers of inpatient clinical decision support alerts, measure the frequency with which they are overridden, and describe providers' reasons for overriding them and the appropriateness of those reasons. We conducted a cross-sectional study of medication-related clinical decision support alerts over a 3-year period at a 793-bed tertiary-care teaching institution. We measured the rate of alert overrides, the rate of overrides by alert type, the reasons cited for overrides, and the appropriateness of those reasons. Overall, 73.3% of patient allergy, drug-drug interaction, and duplicate drug alerts were overridden, though the rate of overrides varied by alert type (P < .0001). About 60% of overrides were appropriate, and that proportion also varied by alert type (P < .0001). Few overrides of renal- (2.2%) or age-based (26.4%) medication substitutions were appropriate, while most duplicate drug (98%), patient allergy (96.5%), and formulary substitution (82.5%) alerts were appropriate. Despite warnings of potential significant harm, certain categories of alert overrides were inappropriate >75% of the time. The vast majority of duplicate drug, patient allergy, and formulary substitution alerts were appropriate, suggesting that these categories of alerts might be good targets for refinement to reduce alert fatigue. Almost three-quarters of alerts were overridden, and 40% of the overrides were not appropriate. Future research should optimize alert types and frequencies to increase their clinical relevance, reducing alert fatigue so that important alerts are not inappropriately overridden.

USA National Phenology Network's volunteer-contributed observations yield predictive models of phenological transitions.

PurposeIn support of science and society, the USA National Phenology Network (USA-NPN) maintains a rapidly growing, continental-scale, species-rich dataset of plant and animal phenology observations that with over 10 million records is the largest such database in the United States. The aim of this study was to explore the potential that exists in the broad and rich volunteer-collected dataset maintained by the USA-NPN for constructing models predicting the timing of phenological transition across species’ ranges within the continental United States. Contributed voluntarily by professional and citizen scientists, these opportunistically collected observations are characterized by spatial clustering, inconsistent spatial and temporal sampling, and short temporal depth (2009-present). Whether data exhibiting such limitations can be used to develop predictive models appropriate for use across large geographic regions has not yet been explored.MethodsWe constructed predictive models for phenophases that are the most abundant in the database and also relevant to management applications for all species with available data, regardless of plant growth habit, location, geographic extent, or temporal depth of the observations. We implemented a very basic model formulation—thermal time models with a fixed start date.ResultsSufficient data were available to construct 107 individual species × phenophase models. Remarkably, given the limited temporal depth of this dataset and the simple modeling approach used, fifteen of these models (14%) met our criteria for model fit and error. The majority of these models represented the “breaking leaf buds” and “leaves” phenophases and represented shrub or tree growth forms. Accumulated growing degree day (GDD) thresholds that emerged ranged from 454 GDDs (Amelanchier canadensis-breaking leaf buds) to 1,300 GDDs (Prunus serotina-open flowers). Such candidate thermal time thresholds can be used to produce real-time and short-term forecast maps of the timing of these phenophase transition. In addition, many of the candidate models that emerged were suitable for use across the majority of the species’ geographic ranges. Real-time and forecast maps of phenophase transitions could support a wide range of natural resource management applications, including invasive plant management, issuing asthma and allergy alerts, and anticipating frost damage for crops in vulnerable states.ImplicationsOur finding that several viable thermal time threshold models that work across the majority of the species ranges could be constructed from the USA-NPN database provides clear evidence that great potential exists this dataset to develop more enhanced predictive models for additional species and phenophases. Further, the candidate models that emerged have immediate utility for supporting a wide range of management applications.

Analysis of Allergy Alerts Registered in a Hospital Electronic Health Record System.

Analysis of Allergy Alerts Registered in a Hospital Electronic Health Record System.

Should Antibiotic Allergy Alerts Be Alarming?

Allergies to various antibiotics are reported by a substantial proportion of patients. As a result, clinical decision support programming generates frequent warnings when prescribing within electronic medical records. For a variety of reasons, the majority of these warnings may be inappropriate. Our improved understanding of the underlying physiology of allergic processes reveals that the majority of cross-reacting antibiotic allergies are implausible. Appropriate history taking and workup can invalidate many more warnings. Electronic medical records ideally should permit documentation that would facilitate more accurate entry and eliminate similar future warnings.

Commentary on "Should Antibiotic Allergy Alerts Be Alarming?"

Commentary on "Should Antibiotic Allergy Alerts Be Alarming?"

Optimization of clinical decision support through minimization of excessive drug allergy alerts.

Computerized provider order entry (CPOE) has been adopted by approximately 86% of hospitals in the United States as of 2014.[1][1] CPOE applications are typically designed with clinical decision support (CDS) systems in place to assist healthcare professionals with therapeutic decisions, including

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement

ObjectivesTo evaluate how often and why providers overrode drug allergy alerts in both the inpatient and outpatient settings.DesignA cross-sectional observational study of drug allergy alerts generated over a 3-year period...

Nonformulary medications can throw a wrench into your CPOE system

Nonformulary medications can throw a wrench into your CPOE system

Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience.

There have been growing concerns about the impact of drug allergy alerts on patient safety and provider alert fatigue. The authors aimed to explore the common drug allergy alerts over the last 10 years and the reasons why providers tend to override these alerts. Retrospective observational cross-sectional study (2004-2013). Drug allergy alert data (n = 611,192) were collected from two large academic hospitals in Boston, MA (USA). Overall, the authors found an increase in the rate of drug allergy alert overrides, from 83.3% in 2004 to 87.6% in 2013 (P < .001). Alarmingly, alerts for immune mediated and life threatening reactions with definite allergen and prescribed medication matches were overridden 72.8% and 74.1% of the time, respectively. However, providers were less likely to override these alerts compared to possible (cross-sensitivity) or probable (allergen group) matches (P < .001). The most common drug allergy alerts were triggered by allergies to narcotics (48%) and other analgesics (6%), antibiotics (10%), and statins (2%). Only slightly more than one-third of the reactions (34.2%) were potentially immune mediated. Finally, more than half of the overrides reasons pointed to irrelevant alerts (i.e., patient has tolerated the medication before, 50.9%) and providers were significantly more likely to override repeated alerts (89.7%) rather than first time alerts (77.4%, P < .001). These findings underline the urgent need for more efforts to provide more accurate and relevant drug allergy alerts to help reduce alert override rates and improve alert fatigue.

FSA food allergen alerts: an analysis of trends in reporting

Background Up to 10% of the paediatric population is affected by food allergy. Affected families face the treat of acute life-threatening reactions, and the burden of chronic decrease in quality of life. UK legislation exists where allergens must be indicated on food labels; any inaccuracies identified must be rapidly revised, and the public informed. This is achieved through Food Standards Agency (FSA) allergy alerts which can be viewed on their website; consumers may also sign up to receive emails or SMS messages when alerts are issued.

Allergic Reaction to a Red Plastic Allergy Alert Patient Identification Bracelet: Implications for Surgical Patient Safety

We present a case of allergy to a hospital thermally-printed red plastic allergy alert bracelet in a 48 year old lady admitted to the day surgery unit. Two hours postoperatively, an intensely itchy area of erythema and oedema was seen extending from her left wrist distally to the fingers. The bracelet was removed and the rash resolved overnight without further complication. A diagnosis of contact dermatitis was made, secondary to exposure to an agent within the bracelet. We discuss the safety implications for surgical patients unable to wear an identification bracelet and the steps that may be taken to minimise the risk of harm from misidentification. We believe this to be the first documented case of an allergy to a patient identification bracelet in the medical literature.

OHP-005 Advantages and Disadvantages of an Electronic Prescribing System. Aspects to Consider During Pharmacist Validation.

BackgroundAn electronic prescribing system (EPS) improves the prescription-validation-administration sequence and reduces errors. Nevertheless new questions can appear and it is interesting to take them into account.Purpose To describe positive and...

Capture and Documentation of Coded Data on Adverse Drug Reactions: An Overview

Allergic responses to prescription drugs are largely preventable, and incur significant cost to the community both financially and in terms of healthcare outcomes. The capacity to minimise the effects of repeated events rests predominantly with the reliability of allergy documentation in medical records and computerised physician order entry systems (CPOES) with decision support such as allergy alerts. This paper presents an overview of the nature and extent of adverse drug reactions (ADRs) in Australia and other developed countries, a discussion and evaluation of strategies which have been devised to address this issue, and a commentary on the role of coded data in informing this patient safety issue. It is not concerned with pharmacovigilance systems that monitor ADRs on a global scale. There are conflicting reports regarding the efficacy of these strategies. Although in many cases allergy alerts are effective, lack of sensitivity and contextual relevance can often induce doctors to override alerts. Human factors such as user fatigue and inadequate adverse drug event reporting, including ADRs, are commonplace. The quality of and response to allergy documentation can be enhanced by the participation of nurses and pharmacists, particularly in medication reconciliation. The International Classification of Diseases (ICD) coding of drug allergies potentially yields valuable evidence, but the quality of local and national level coded data is hampered by under-documenting and under-coding.

Corrigendum: Improvement of the Drug Allergy Alert for Nonprescription NSAIDs

Corrigendum: Improvement of the Drug Allergy Alert for Nonprescription NSAIDs

Allergy alerts in electronic health records for hospitalized patients

BackgroundElectronic health records (EHRs) are used to register important health-related information, such as allergic conditions, and contribute to the safety and quality of medical care. ObjectivesTo evaluate the use of allergy alert entries in EHRs and to establish the allergy profile of hospitalized patients. MethodsAllergy data recorded in EHRs were analyzed in a cross-sectional, observational, descriptive study of patients admitted to the hospital from January 1 through June 30, 2011. ResultsA total of 15,534 patients were admitted to the hospital during the study period. The rate of inclusion of allergy information in the EHRs was 64.4%. In 2,106 patients an alert was activated to declare an allergy, intolerance, or any other type of adverse reaction. Drugs were the most common responsible agent (74.4%), followed by foods (12.6%) and materials (4.8%). Entries for drug allergy or intolerance were more common in females (64.8%) than males, with a significant statistical difference (P < .01), and increased proportionally with age. Entries for food allergy or intolerance were also more common in females (58.0%) than males (P < .01), but this trend was reversed in the 0- to 15-year-old age group. By contrast, the entries for food allergy or intolerance decreased proportionally with age. In 7,907 cases the EHRs revealed that patients were free of allergies, intolerances, or any other type of adverse reactions. ConclusionDrug allergy was the most frequently reported allergic condition, followed by foods and materials. Allergy alerts vary depending on age and sex. The proper use of a system for allergy alerts included in EHRs provides valuable information about hospitalized patients, contributing to the improvement of clinical practice.

Improvement of the Drug Allergy Alert for Nonprescription NSAIDs

Objective The purpose of the study was to compare revised and current ibuprofen over-the-counter (OTC) allergy alerts for usability, readability, and overall preferences in consumers naive to drug allergies and drug-induced allergy survivors.