Drug allergy documentation--time for a change?

To audit patients' allergy documentation in a large rural hospital an to make recommendations about accurate drug allergies in hospital settings.

A 257 bed large hospital and fully integrated health service in Australia, providing a range of services including; medicine, surgery, aged care, cancer care, mental health, maternity and rehabilitation.

A retrospective design was used to fulfil the aims of this study. Patient medical records were randomly selected and checked for allergy documentation over a 6 month period.

A total of 521 patients' medical records were reviewed. Of all the medical records examined in total, 269 (52%) had no allergy, while 252 (48%) reported some kind of allergy. Overall, only three patients (0.6%) had their allergy details fully and accurately recorded in the three places audited and they are the front cover of the patients' notes, the admission notes and the drug chart.

Many preventable medical errors are caused by poor documentation which is often due to lack of drug allergy information. All health professional should be more pro-active in determining the manner of any drug allergy or adverse drug reactions (ADR) along with the extent of the reaction.