Eneh Oliaku, Fahy Sabina
Department of Psychiatry,MidlandRegional Hospital,Portlaoise,Co. Laois,Ireland.
St Brigid's Hospital,Ballinasloe,Co Galway,Ireland.
Ir J Psychol Med. 2011 Dec;28(4):213-216. doi: 10.1017/S079096670001168X.
This audit aimed to: identify the level of allergy documentation in admission notes, case notes and medication charts in the Department of Psychiatry, Portlaoise; establish the degree of compliance to the gold standard guidelines; highlight areas requiring further improvement and make realistic recommendations to ensure better compliance with the stipulated guidelines on allergy documentation; and re-audit after six months.
Gold standard guidelines on allergy documentation were obtained from various sources. Audit was performed over three days during which data was collected from the allergy section of medication charts, current case notes and original admission notes in both acute and long-stay wards. Recommendations were made and some were adopted, changes to practice were implemented for six months; at which time re-audit was performed.
The initial audit revealed that: the allergy section was completed in 25% of medication charts; only 12% of current case notes had any documentation of allergy status; an for the original admission notes, the allergy section was documented in 65% of notes. Based on these results, a formal initial assessment proforma with a designated allergy section was introduced and a renewed awareness of the importance of the documentation of allergy status was actively promoted amongst non consultant hospital doctors (NCHDs). Six months later, re-audit showed that: in the medication charts there was a significant improvement in the level of compliance with documentation of allergy status (allergy or NKDA) in the allergy section up from 25% to 58.1%; in the current case notes, there was only marginal improvement in the level of compliance on the front of case notes from 12-19.1%; and in the original admission notes, there was also considerable improvement in the level of compliance with documentation of allergy status up from 65% to 80.9%.
This audit improved the level of documentation of allergy sections in the relevant areas and therefore helped in preventing avoidable and potentially fatal allergic reactions. It will also help save money for the Health Service Executive by reducing compensation costs filed by patients.
本次审核旨在：确定波特劳伊斯精神病科入院记录、病历和用药记录中的过敏记录水平；确定对金标准指南的遵守程度；突出需要进一步改进的领域，并提出切实可行的建议，以确保更好地遵守关于过敏记录的规定指南；并在六个月后进行重新审核。
从各种来源获取关于过敏记录的金标准指南。审核在三天内进行，期间从急性和长期住院病房的用药记录过敏部分、当前病历和原始入院记录中收集数据。提出了建议，部分建议被采纳，对实践的改变实施了六个月；届时进行重新审核。
首次审核显示：25%的用药记录完成了过敏部分；只有12%的当前病历有任何过敏状态记录；对于原始入院记录，65%的记录中有过敏部分记录。基于这些结果，引入了带有指定过敏部分的正式初始评估表格，并在非顾问医院医生（NCHD）中积极宣传重新认识过敏状态记录的重要性。六个月后，重新审核显示：在用药记录中，过敏部分记录过敏状态（过敏或无已知过敏）的遵守水平有显著提高，从25%升至58.1%；在当前病历中，病历首页的遵守水平仅略有提高，从12%升至19.1%；在原始入院记录中，过敏状态记录的遵守水平也有相当大的提高，从65%升至80.9%。
本次审核提高了相关领域过敏部分的记录水平，因此有助于预防可避免的和潜在致命的过敏反应。它还将通过减少患者提出的赔偿费用，帮助为卫生服务执行局节省资金。
