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Drug allergy documentation by physicians, nurses, and medical students
A K Pau1, J E Morgan, A Terlingo
1Department of Pharmacy Practice, College of Pharmacy, University of Illinois, Chicago 60612.
American Journal of Hospital Pharmacy
|March 1, 1989
Summary
Healthcare professionals often fail to accurately document patient drug allergies. Patients possess accurate knowledge, but this information is frequently missing from medical records, impacting patient safety.
Area of Science:
- Clinical Pharmacy
- Patient Safety
- Medical Documentation
Background:
- Accurate drug allergy documentation is crucial for patient safety.
- Gaps in documentation can lead to adverse drug events.
- Understanding patient knowledge versus documented information is essential.
Purpose of the Study:
- To assess the completeness and accuracy of drug allergy documentation by healthcare professionals.
- To evaluate patients' knowledge of their own drug allergy status.
- To identify discrepancies between documented and reported drug allergies.
Main Methods:
- Review of admission notes for adult medicine patients with drug allergies.
- Identification of drug allergies via chart labels.
- Patient interviews to gather information on drug hypersensitivity.
- Classification of reactions as true allergic, nonallergic adverse, or unclassifiable.
Main Results:
- Significant discrepancies found between drugs listed on charts and reported by patients.
- Approximately 20% of healthcare professionals failed to document drug allergies in admission notes.
- Patients could recall key reaction details, but this information was not documented.
Conclusions:
- Incomplete drug allergy documentation is prevalent.
- Patient recall of allergy information is generally accurate.
- Documentation deficits are not due to patients' inability to provide information.