OBJECTIVE: To assess the implementation of local and national guidelines concerning documentation of drug/clinical hypersensitivities. DESIGN: Audit with retrospective and prospective components used to assess the process of drug hypersensitivity documentation. PATIENTS: Fifty surgical inpatients' notes were retrospectively analysed followed by 63 patients prospectively. SETTING: West London teaching hospital. MAIN OUTCOME MEASURES: Drug hypersensitivity status correctly indicated on clinical notes, drug 'Kardex' charts, and anaesthetic records; these three documents were to concur. Hypersensitivities qualified according to symptoms experienced. RECOMMENDATIONS: Standardization of preoperative clinical notes and multidisciplinary responsibility for records between doctor, nurse and pharmacist. RESULTS: Hypersensitivity documentation in clinical notes improved by 7% after the introduction of a formalized history sheet for preoperative clinics. These were based upon the anaesthetic charts, which had demonstrated 100% documentation previously. Considerable improvements (70.8%) in the clarification of adverse reaction symptoms post recommendation were shown; this was also attributed to the new history sheet. Concurrence improved by 2%. CONCLUSIONS: The original study revealed areas for improvement and provided part of the solution--a more standardized preoperative assessment tool. Multidisciplinary cooperation in addition to formalizing the assessment process has led to a more efficient and safer service for patient and medicolegally for health care professionals. KEY MESSAGES: (1) Standardized forms, for the recording of clinical information preoperatively, ensure relevant guidelines are implemented in practice. (2) Multidisciplinary teams provide a vital safety net for their patients and colleagues.
OBJECTIVE: To assess the implementation of local and national guidelines concerning documentation of drug/clinical hypersensitivities. DESIGN: Audit with retrospective and prospective components used to assess the process of drug hypersensitivity documentation. PATIENTS: Fifty surgical inpatients' notes were retrospectively analysed followed by 63 patients prospectively. SETTING: West London teaching hospital. MAIN OUTCOME MEASURES: Drug hypersensitivity status correctly indicated on clinical notes, drug 'Kardex' charts, and anaesthetic records; these three documents were to concur. Hypersensitivities qualified according to symptoms experienced. RECOMMENDATIONS: Standardization of preoperative clinical notes and multidisciplinary responsibility for records between doctor, nurse and pharmacist. RESULTS:Hypersensitivity documentation in clinical notes improved by 7% after the introduction of a formalized history sheet for preoperative clinics. These were based upon the anaesthetic charts, which had demonstrated 100% documentation previously. Considerable improvements (70.8%) in the clarification of adverse reaction symptoms post recommendation were shown; this was also attributed to the new history sheet. Concurrence improved by 2%. CONCLUSIONS: The original study revealed areas for improvement and provided part of the solution--a more standardized preoperative assessment tool. Multidisciplinary cooperation in addition to formalizing the assessment process has led to a more efficient and safer service for patient and medicolegally for health care professionals. KEY MESSAGES: (1) Standardized forms, for the recording of clinical information preoperatively, ensure relevant guidelines are implemented in practice. (2) Multidisciplinary teams provide a vital safety net for their patients and colleagues.
Authors: Eric S Kiechle; Colleen M McKenna; Hannah Carter; Alexander Zeymo; Bradley W Gelfand; Lindsey M DeGeorge; Diane A Sauter; Maryann Mazer-Amirshahi Journal: J Med Toxicol Date: 2018-07-02