Improving Allergy Status Documentation on Electronic Patient Records- a Trust-Wide In-Patient Quality Improvement Project

Aims NICE guideline CG183 states that “both the drug and description of reaction must be documented on all forms prescription in a patient's medical records”. Black Country Partnership NHS Foundation Trust (BCPNFT) documents allergy status both paper charts Electronic Patient Record“"Ri”" (EPR). Incomplete Allergy Status EPR poses significant patient safety risk, particularly an era hybrid working out hours input from remotely based clinicians. The standard for this audit is 100% Rio notes should have documented. BCPNFT collection psychiatric services across four towns- Dudley, Walsall, West Bromwich Wolverhampton. aim was to ensure consistent practice standards sites. Following initial data collection, discussion findings Action Plan (AP), standards, it agreed expand project include General Adult in-patient units. Methods A tool designed collaboratively with QI Department, capture demographics, diagnosis, admission duration, legal written digital. This applied 96 older adult in-patients localities within trust 03.10.22. only exclusion criteria 24 date. Results Data Collection: Paper Drug Charts had documented, 70% type or severity allergic Despite 76% 4 weeks longer, 62% patients their EPR, varied 30-100% individual wards. documented: Wolverhampton 93% Dudley 33% Walsall 39% Conclusion results were presented at respective locality post graduate teaching, configuration team meeting Group gain Multi-Disciplinary Team feedback low documentation rates high variability Based feedback, AP comprised incorporating prompt into electronic clerking document, visual prompts stickers posters Also, liaising Pharmacy request they also update EPR; Ward Matrons who added alert onto bed state view. will then recollected interventions, age inpatient wards- sample size around 300 patients. second currently being undertaken.