Accuracy of drug-allergy recording in a district general hospital.

OBJECTIVES: The aim was to audit the accuracy of drug-allergy documentation in a District General Hospital.
METHODS: A drug card and case-note review was used. The subjects of the study were 117 medical and surgical current inpatients in a District General Hospital. Outcome measures were information collected, including whether the drug hypersensitivity box was filled in on the drug card, what was written in the box and whether this was signed and dated. The information on drug allergies was then checked with the patients. The medical notes were audited for a completed ALERT sheet and its accuracy. KEY
FINDINGS: Sixty-nine patients in this study were on surgical wards, and 48 were on medical wards. Some 97.4% had the drug-allergy box on the drug card filled in to some extent, and only three (2.6%) had nothing documented. Including those boxes that were blank, 32 (27.4%) were signed and 22 (18.8%) were dated. Twelve patients (10.3%) stated that the allergy information recorded about them was incorrect. The ALERT forms in the medical notes were only filled in on 58.1% of occasions (i.e. they had a patient addressograph label), and of those that were completed, 36.5% did not match the information on the drug card.
CONCLUSIONS: Although doctors ask about drug allergies, documentation is not done well for a number of reasons, including the design of the drug card. Currently there is a blank allergy box with no guidance about what should be written there. The new drug card to be introduced in the next few months will distinguish between true drug allergies and side effects. It will also prompt the nature of the allergy to be documented, from whom this information was obtained, and the signature of the person filling in the information. Failure to accurately document drug allergies leads to the potential for doctors to prescribe medication that could be harmful for the patient.