Improving the Accuracy and Safety of Allergy Documentation Through a Standardized Recording System: A Quality...

Incomplete allergy documentation is a major contributor to medication errors and adverse drug events. At Atbara Teaching Hospital, allergy information was inconsistently recorded, with no standardized format or visible alert system. This audit aimed to improve the completeness and accessibility of allergy documentation through the introduction of a structured sticker and brief staff training.

A two-cycle clinical audit was conducted in the Department of Internal Medicine at Atbara Teaching Hospital, Sudan, between August and October 2025. The first cycle reviewed 50 inpatient records to establish baseline compliance with international documentation standards. Following this, a standardized "Allergy Documentation Sticker" was designed and implemented, accompanied by short educational sessions for staff. The second cycle reviewed another 50 records post intervention. Data were analyzed using descriptive statistics and chi-square tests for significance.

Baseline compliance with allergy documentation standards was poor. Fields such as allergen, reaction type, and severity were absent in all records (0/50, 0%). After introducing the sticker, compliance improved significantly to 50/50 (100%) for these parameters (p < 0.001). Documentation of "Any Known Allergy?" increased from 25/50 (50%) to 50/50 (100%) (p < 0.001), while doctor name and signature improved from 0/50 (0%) to 39/50 (78%) (p < 0.001). Minor improvements were also observed in demographic details, such as "unit" (38/50 (76%) → 45/50 (90%)). Overall, statistically significant gains were recorded across most fields, reflecting enhanced accuracy, accountability, and visibility of allergy records.

Introducing a structured allergy documentation sticker significantly improved the quality and completeness of allergy recording in a paper-based hospital setting. The intervention was low-cost, sustainable, and adaptable, aligning with global patient safety priorities. Regular audits, continued education, and progressive digital integration are recommended to sustain these improvements.