Documentation of Allergies on Inpatient Medication Charts.

Sir Medication allergies are common and can result in significant morbidity and mortality, allergic drug reactions have an estimated mortality rate of 0.09 per 1,000 hospital admissions. 1 In Ireland medication allergies accounted for 2% of medication events reported, according to the Irish Medication Safety Network. 2 Therefore documentation of allergies on medication charts is commonplace in order to prevent or minimise potential adverse reactions due to known allergens. Previous research from an Irish hospital had shown that only 70% (211/300) of charts examined had a completed drug allergy box. 3 An audit was carried out with the aim of ascertaining the proportion of medication charts which had medication allergies documented, in addition to details of the allergy and completed prescriber information. All inpatient medication charts in St Columcille’s Hospital, Loughlinstown were reviewed on one particular afternoon (25th November 2014). Current medication charts used in St Columcille’s Hospital require documentation of any allergy, in addition to the nature of the reaction, whether the agent should be used with caution or is contraindicated and the person should sign, date and provide an identifier (e.g. bleep number, Irish Medical Council registration number). Entries which were illegible were recorded as not documented. The total number of inpatients was 69, 100% of charts were reviewed. On 96% (n=66) of patients’ charts an allergen or "no known drug allergy" was documented. Of the 66 patients who had this information documented, 22 (33%) had an allergy. Of the 22 patients with a documented allergy, the majority were due to antibiotics (55% n=12). 14 (64%) had the nature of the reaction documented and on 14 charts (64%) it had been noted if the medication was contraindicated or could be used with caution. A signature and identifier was present on 64 (93%) charts. Given the importance of allergy documentation it is reassuring that 96% of medication charts had this documented. In comparison with previous studies this is an improvement, from 70% previously reported in an Irish hospital and 84% (211/300) in an Australian study. 3,4 However there were still 3 charts (4%) with no documentation, and it cannot be assumed that these patients had no known drug allergies. One third of patients were recorded as having an allergy, which is a significant proportion. This highlights the importance of documenting not only the medication but also the details of the reported allergy. 36% of charts were lacking details regarding the nature of the reaction and if the medication was contraindicated. This information is important and if missing the prescriber would have to assume that the medication was contraindicated and therefore limit pharmacological choices. In summary 96% of inpatients in St Columcille’s Hospital had their medication allergy information documented. However, of the 22 (33%) patients with allergies further information which could aid prescribers was lacking in 36%. An information session has been provided to Non-Consultant Hospital Doctors regarding the audit findings, and importance of documentation. Healthcare professionals should not become complacent with allergy documentation and details, otherwise preventable morbidities and mortality could result. E Beary, Y Lillis St Columcille’s Hospital, Loughlinstown, Co Dublin Email: [email protected]