An audit of the completeness and accuracy of allergy-status documentation
To assess whether or not the allergy status and the nature of the allergy for patients admitted to Sandwell and West Birmingham Hospitals NHS Trust were recorded accurately.
In addition, to determine if patients with true allergies were wearing a red identification bracelet as required by trust policy.
Over a six-month period, the medical records of 200 inpatients from medical and surgical wards were examined for documentation of allergy status, which was then verified using a questionnaire. Those patients who reported allergies were checked as to whether they were wearing a red identification bracelet.
Allergy status was recorded in 177 patients’ drug charts, 170 patients’ medical clerking and only 6 alert sheets. In total, 36 patients were found to have true allergies. Only 11 of these patients had their allergy status documented fully in both the medical clerking and on the drug chart. Three had their allergy status incorrectly recorded as “no known drug allergy” in the medical clerking and seven had no red identification bracelet.
Our audit identified that allergy-status recording at SWBHT was incomplete or inaccurate for the majority of patients. Urgent measures are required to address this deficiency in clinical practice.
We were aware from our clinical practice that documentation of patients’ allergy status was not always complete or accurate. Additionally, at Sandwell and West Birmingham Hospitals NHS Trust, allergy status could be recorded in a number of locations (the drug chart, medical clerking, initial assessment form, alert sheet and electronic patient record).
We decided to conduct an audit to see how well allergy status was documented, and to see if this concurred with what patients knew about their allergies.
We found there were numerous inconsistencies in allergy-status documentation, with some allergic patients being incorrectly labelled as having “no known drug allergies” (and vice versa). Of the documentation that could be completed, the electronic patient record and the alert sheet were the least used.
The results showed that not only was our allergy recording not optimal, there was also unnecessary duplication in recording allergies and a lack of clarity in trust policies regarding allergy recording.
As a result of this audit we plan to review all documentation within the trust where allergy status is, or should be, recorded with the aim of reducing duplication and clarifying who can record allergy status.
This will have to be supported by a training package aimed at appropriate staff. Electronic prescribing within the trust will bring a different set of challenges in the future.
The full text article is available to read as a PDF (850K).
Roshini Kalliat and Nicolette Smith are clinical effectiveness audit co-ordinators, Emma Graham-Clarke is consultant pharmacist for critical care and K-L Kong is a consultant anaesthetist, all at Sandwell and West Birmingham Hospitals NHS Trust.
Citation: Clinical Pharmacist URI: 11040189
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