Audit of the Documentation of Drug Allergy Status at the Royal Alexandra Hospital

Abstract

Objectives: The aim of this audit was to explore the documentation of drug allergy status among patients in the Royal Alexandra Hospital (RAH). Methods: This prospective study examined drug administration charts (Kardexes) and pro-formas (admission clerk-in document) in patients’ medical notes. The audit included 380 inpatients from medical, surgical and elderly care wards in the RAH. Outcome measures included whether the drug allergy section was completed on the Kardex, what was written there and whether this information had been reviewed by the pharmacy team. The pro-forma was checked to assess whether allergy information was documented. Results: Among the 380 patients in this audit, 332 (87%) had the drug-allergy box on the Kardexes filled in to some extent; 205 (54%) patients had no known allergies and 127 (33%) had known allergies. For patients with known allergies, in all (100%) cases the prescriber specified the type of the drug allergies. The most commonly reported drug allergies in these patients were penicillins (21%). Additionally, (24%) of the prescribers reported the symptoms of drug allergies. Of the 232 Kardexes reviewed by the pharmacy team, allergy status was documented on 212 (91%). Allergy status in the pro-forma was recorded on 131 (34%) of the 380 medical notes. Conclusions: The documentation of patients’ allergy status did not meet the audit standard, particularly regarding the signs and symptoms of drug allergies. Failure to accurately document drug allergies may result in healthcare providers prescribing medication that could be harmful to the patient. A potential solution might be to redesign the allergy box on the Kardex and thus that it may not be left blank and to clearly distinguish true allergies from side effects.