Who should collect allergy information and how should it be done?

pulling out hairA pharmacists review of a patient medication regimen is never complete without a thorough evaluation of the patients allergy history. Unfortunately our hospital information system suffers from the inability to prevent people from being human and making mistakes. Our clinical information system permits ‘free texting’ of allergy information, resulting in misspelled drug names and therefore allergies that aren’t electronically checked against medication orders. You know the old saying: garbage in, garbage out.

At our facility, allergy information is collected by nursing staff at the time of admission. While competent and intelligent, nurses are not generally in tune with the intricacies of taking a good drug allergy history; they have other pressing matters to deal with. As a result the accuracy of drug allergy information located in the patient’s medical record is often less than complete.

Pharmacists on the other hand are interested in everything related to medications, which includes allergies. Most patients don’t know whether or not they’re allergic to a medication, much less what the details are surrounding the allergy. Believe it or not, not all medication allergies are, in fact, allergies. Some perceived allergic reactions can be classified as an adverse reaction, a drug intolerance or simply an expected side effect.

If you get stomach upset from aspirin that’s not an allergy. How about if I fall asleep after taking a Valium? Definitely not. Well, what if I feel dizzy with my new beta-blocker dose? Nope. I get constipated when I take my morphine. Take a stool softener. What if I turn red and can’t breathe after taking penicillin? Yep, you’ve got an allergy.

Did you know that food allergies can affect how you tolerate medications? No. Well they can. For example, if you’re allergic to eggs you may not be able to receive certain vaccines and immunizations, and if you have a severe peanut allergy you should be careful with certain inhalers used to treat asthma and COPD. While not as glamorous as a good medication allergy, this is important information.

The trick with any good allergy history is to dig deep into the matter. Pharmacists, and other healthcare professionals, need to know what medication was taken, when it happened, what the reaction was, how long after taking the medication, how long the reaction lasted, whether or not the patient has taken any related medications and how they were tolerated, etc. It is imperative that pharmacists have this information if they are to make accurate decisions regarding drug therapy. Technology alone can’t do this.

During my fourth year as a pharmacy student at UCSF I was assigned to a general medicine team as part of my clinical rotations. The team consisted of an attending physician, a chief resident, three junior residents, two medical students and one pharmacy student; me. Every so many days this particular team would be responsible for the patients admitted to the hospital through the emergency department. Part of my job was to obtain a detailed medication history from every patient admitted to our service. The medication history included detailed information on the patient’s allergies. You wouldn’t believe the stuff I found by questioning patients. Of course, after taking the history I would enter all the information into the hospital information system for the rest of the medical team.

This brings me to my point; no matter what advances are made in technology, a change in practice in necessary to bring about a safer way to collect allergy information from patients. The best way to accomplish this is to move the pharmacist away from the physical pharmacy and into the trenches where they can interact with the patients. This is especially true in high-risk areas like the emergency department where patient information is first collected. I realize that computer technology is great, but at this time it cannot replace a good pharmacist. However, it can help a pharmacist do his job better and more efficiently. Just a thought.

8 thoughts on “Who should collect allergy information and how should it be done?”

  1. Hi Jerry,

    Great piece of writing. In the UK pharmacists have been out in the trenches for at least the last 25 years, performing just this sort of task.

    However, with the advent of electronic systems there is a danger that it may be seen as an opportunity to do much more work remotely.

    Some of our systems use Snomed CT as the underlying coding for allergy recording, and indeed I spent a substantial length of time producing a subset of terms suitable for allergy recording (think it was over 2000 causative agents). However, the user interface in some systems is not good enough and it will need skill and knowledge in order to correctly select and record the allergy. Many, possibly all, systems allow freetext entry either in addition or instead of coded entry if allergy entries.

    A study carried out by a London hospital some years ago showed that nurses tended to record exactly what the patient said, and included terms such as phobias (spiders), preferences (Mondays), and humour (mother in laws) in recorded allergies. Whilst there is some merit in recording such things as they give a fuller picture if the patient they clearly have no use in computerised allergy checking. If nurses become accustomed to using the freetext entry for these things (or actual allergy causative agents) they will prevent the computer checking the agent against prescribed items.

    I believe that pharmacists (of which I am one) have a huge role to play in the frontline, recording, checking, and amending allergy records and also educating others who have access to the electronic recording if allergies.

    Pharmacists should be key people in the selection of prescribing systems. They have the knowledge to design and configure the allergy modules. They have the skills to teach the optimal use of such systems to the other clinical staff, in the same way that they currently teach safe prescribing, pain relief, inhaler technique and the rest either formally or informally.

    I agree entirely with your article. Now, more than ever, pharmacists need to be out there alongside the patients. Technology can assist all of us to provide better care for our patients, but it needs careful monitoring, improvement and education of staff, all of which tasks are in the core skill set of the pharmacists. Hospital management needs to understand how important pharmacists are in the business of the incident (and litigation) prevention.

    Best regards


  2. What is the problem with inhalers for asthma and COPD if you have a severe peanut allergy? I have never heard of this. This would be very important information for peanut allergy sufferers.

  3. Ah, yes. Combivent and ipratropium inhalers have been know to cause problems for individuals with severe peanut or soy bean allergies. Talk with your physician or pharmacist about it if you need more information.

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