Antibiotic allergy: inaccurate history taking in a teaching hospital.
To evaluate the accuracy of allergy histories obtained by interns, residents, and ward attending physicians, we compared physician-charted allergy histories with our own concurrently performed histories over a 2-month span for all general medicine and surgery patients admitted to a 615-bed suburban teaching hospital. We found 100% agreement between investigator and charted histories for all 318 (88%) of 363 charts identifying no known allergy. We disagreed with 23 (50%) of 46 allergies documented in the charts of the remaining 45 patients. Concurrent review classified 18 (39%) of these 46 charted allergies as clinically unimportant, and 5 charts (11%) were deemed underclassified. A description of the allergy by the primary physician was documented in only 7 charts (16%). Inaccurate allergy histories are frequently documented in the medical record. Simple adjustments in history taking and supervision may have important implications for patient care and training.
Absy
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Division of Infectious Diseases, Nassau County Medical Center, East Meadow, NY.
Glatt
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D000707:Anaphylaxis / Q000175:diagnosis / Q000473:pathology; D000900:Anti-Bacterial Agents / Q000009:adverse effects*; D003211:Concurrent Review; D003937:Diagnosis, Differential; D004342:Drug Hypersensitivity / Q000175:diagnosis* / Q000473:pathology; D006757:Hospital Units; D006784:Hospitals, Teaching; D006801:Humans; D007396:Internship and Residency; D008487:Medical History Taking; D008505:Medical Staff, Hospital; D010820:Physicians; D013503:Surgery Department, Hospital
D000900:Anti-Bacterial Agents