Recording of drug allergies: are we doing enough?

OBJECTIVE

To assess the implementation of local and national guidelines concerning documentation of drug/clinical hypersensitivities.

DESIGN

Audit with retrospective and prospective components used to assess the process of drug hypersensitivity documentation.

PATIENTS

Fifty surgical inpatients' notes were retrospectively analysed followed by 63 patients prospectively.

SETTING

West London teaching hospital.

MAIN OUTCOME MEASURES

Drug hypersensitivity status correctly indicated on clinical notes, drug 'Kardex' charts, and anaesthetic records; these three documents were to concur. Hypersensitivities qualified according to symptoms experienced.

RECOMMENDATIONS

Standardization of preoperative clinical notes and multidisciplinary responsibility for records between doctor, nurse and pharmacist.

RESULTS

Hypersensitivity documentation in clinical notes improved by 7% after the introduction of a formalized history sheet for preoperative clinics. These were based upon the anaesthetic charts, which had demonstrated 100% documentation previously. Considerable improvements (70.8%) in the clarification of adverse reaction symptoms post recommendation were shown; this was also attributed to the new history sheet. Concurrence improved by 2%.

CONCLUSIONS

The original study revealed areas for improvement and provided part of the solution--a more standardized preoperative assessment tool. Multidisciplinary cooperation in addition to formalizing the assessment process has led to a more efficient and safer service for patient and medicolegally for health care professionals.

KEY MESSAGES

(1) Standardized forms, for the recording of clinical information preoperatively, ensure relevant guidelines are implemented in practice. (2) Multidisciplinary teams provide a vital safety net for their patients and colleagues.