| Purpose: |
This policy is written to
define steps in allergy identification and medication administration as
it relates to patient allergy
|
| Procedure: |
Identification of patient allergies occurs at time of admission.
Preadmission packet information is reviewed for allergy information by the
admitting nurse. The patient (and guardian or family member) are interviewed
by physician and nurse to establish presence of allergies. Information is
entered on line so that all disciplines have access to allergy information.
Pharmacy views information during medication dispensing. Physicians view
information during medication ordering process. Nurses view information
as part of medication administration process. All disciplines are responsible
for updating information based on additional information received during
the course of assessment or treatment. The person who identifies the additional
allergy information updates this information online in the health issues
section of Sunrise upon receipt of the information. |
| Admission Assessment Process: |
- Admission packet information (including allergies) is reviewed by
admitting physician and admitting nurse.
- Admitting Dr asks patient if he/she has any allergies to food or
medicine.
- Admitting nurse asks patient if he/she has any allergy to medicine
or food and documents allergy in the allergy summary in the clinical
manager. The information is then again captured in the online nurse
admission assessment. If patient reports allergy, admitting nurse enters
separate screen for each medication allergy listing med item patient
is allergic to and type of response reaction the patient experiences.
- Food allergies are documented online in the allergy summary and also
in the
nurse assessment under appetite and food.
- Any allergies identified post admission are added to the health issue
allergy summary section in Sunrise.
|
| Data Flow: |
Allergy information entered into Sunrise populates MAR and
the MD order form immediately as it is entered (exception: Allergies entered
as part of nurse assessment)
Allergy data goes immediately to Pharmacy electronically as part of the
MD order. |
| Identification of Patient Allergy at
Time of Admission: |
- Admissions RN asks patient of known allergy as part of admission assessment process
and documents online. Patient registration dept staff member applies armband in pt registration
department.
- RN admitting the patient reviews information under the patient information "Summary"
tab in the online medical record. If there is no allergy information
documented there, the RN is to initiate the capture of this information
by adding the identified allergies (including “No Known Allergies”)
using the Allergy Summary icon or the Red button on the Allergy Summary
page or by using the data entry feature under the “Patient Info”
tab.
- Patient’s who have been a client here before and have had allergy
information documented during previous hospitalizations will have that
information move forward into all new visits. The RN admitting the patient
reviews the Allergy information under the “Summary “ tab
with the patient to verify it’s correctness. If the information
needs to be updated, the nurse has the ability to do so at that time.
- If a patient is unable to review this information or to provide true
allergy information at the time of admission due to severe mental illness,
the RN/MD is to record that as “Allergy Status Unknown”.
- Review of and/or updating of allergy information is to be done prior
to initiating the Nursing Assessment as the data pulled into the document
derives from the Allergy Summary data.
|
| Identification of allergy at time of
medication ordering |
The physician reads the allergy on the physician order form
when medication is ordered. If there is no allergy, the physician is prompted
to ask whether there is an allergy before the order is entered. |
| Identification of allergy at time order
is dispensed |
- The pharmacist reads the allergy which prints with the order. The
pharmacist makes sure the order is not for a medication the patient
has reported an allergy to.
- If pharmacist identifies a discrepancy, medication is not dispensed.
Ordering physician is called by pharmacist. See process for med error
reporting
|
| Identification of allergy at time of
medication administration |
- It is the responsibility of the person administering meds to check
the allergies at the time of medication administration
- The RN/LVN reads the allergies printed on the MAR to make sure patient
has no listed allergies to each med before it is administered.
- In case of medical emergency, first responding MD and nurse check
to establish allergy before medication is administered.
|
| Medication Error Process |
Dispensing, ordering or administering medication the patient
has reported allergy to
is considered a medication error. See Medication error reporting process. |
