Gay Kathryn J, Hill Christopher, Bell Thomas
Kings Mill Hospital, Mansfield Road, Sutton in Ashfield, Nottinghamshire, UK.
Int J Pharm Pract. 2009 Aug;17(4):253-5.
The aim was to audit the accuracy of drug-allergy documentation in a District General Hospital.
A drug card and case-note review was used. The subjects of the study were 117 medical and surgical current inpatients in a District General Hospital. Outcome measures were information collected, including whether the drug hypersensitivity box was filled in on the drug card, what was written in the box and whether this was signed and dated. The information on drug allergies was then checked with the patients. The medical notes were audited for a completed ALERT sheet and its accuracy.
Sixty-nine patients in this study were on surgical wards, and 48 were on medical wards. Some 97.4% had the drug-allergy box on the drug card filled in to some extent, and only three (2.6%) had nothing documented. Including those boxes that were blank, 32 (27.4%) were signed and 22 (18.8%) were dated. Twelve patients (10.3%) stated that the allergy information recorded about them was incorrect. The ALERT forms in the medical notes were only filled in on 58.1% of occasions (i.e. they had a patient addressograph label), and of those that were completed, 36.5% did not match the information on the drug card.
Although doctors ask about drug allergies, documentation is not done well for a number of reasons, including the design of the drug card. Currently there is a blank allergy box with no guidance about what should be written there. The new drug card to be introduced in the next few months will distinguish between true drug allergies and side effects. It will also prompt the nature of the allergy to be documented, from whom this information was obtained, and the signature of the person filling in the information. Failure to accurately document drug allergies leads to the potential for doctors to prescribe medication that could be harmful for the patient.
旨在审核一家区综合医院药物过敏记录的准确性。
采用药物卡片及病例记录审查的方式。研究对象为一家区综合医院的117名内科及外科住院患者。观察指标为收集到的信息，包括药物卡片上的药物过敏栏是否填写、栏内填写的内容以及是否有签名和日期。随后与患者核对药物过敏信息。审核病历中是否有完整的警示单及其准确性。
本研究中69名患者在内科病房，48名在外科病房。约97.4%的患者药物卡片上的药物过敏栏有一定程度的填写，只有3名（2.6%）无任何记录。包括空白栏在内，32份（27.4%）有签名，22份（18.8%）有日期。12名患者（10.3%）表示记录的关于他们的过敏信息有误。病历中的警示单仅在58.1%的情况下填写（即有患者姓名住址打印标签），且在已填写的警示单中，36.5%与药物卡片上的信息不符。
尽管医生会询问药物过敏情况，但由于多种原因，记录工作做得并不好，包括药物卡片的设计。目前有一个空白的过敏栏，且没有关于应填写内容的指导。未来几个月将引入的新药物卡片将区分真正的药物过敏和副作用。它还将提示记录过敏的性质、信息来源以及填写信息者的签名。未能准确记录药物过敏情况可能导致医生开出对患者有害的药物。
