Hospital Pharmacist
2006;13:257-258
July/August 2006

Auditing the recording of allergy status in community hospitals

By Amanda Tempest, RegPharmTech

Failures to record on a drug chart that a patient has a drug allergy can have serious consequences. This article describes the results of an audit carried out at four community hospitals in Sussex and suggests ways in which allergy status recording can be improved

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Failing to record a patient’s allergy status accurately can have serious consequences. Therefore, guidance set out in “Building a safer NHS for patients: improving medication safety” includes:¹

· The allergy status of the patient should be documented on all hospital charts used for prescribing medicines so that it is visible at the point of prescribing, dispensing and administration

· The allergy status of patients should be written in a prominent position in the medical notes and referred to each time the patient is reviewed by a member of the clinical team. (This should be done even when the patient has no known allergies.)

Similarly, in the Nursing and Midwifery Council guidelines for the administration of medicines², nurses are reminded to check that the patient is not allergic to the medicine before administering it.

Despite these good practice requirements, it was clear that allergy status was not always being recorded appropriately in community hospitals in Sussex Downs and Weald Primary Care Trust.

There are four community hospitals in the PCT, which together have approximately 110 beds (about 80 medical inpatient beds [GP-led, intermediate care, rehabilitation, respite care and district nurse led] and 30 surgical inpatient and day-patient beds), minor injury units and outpatient clinics. Initially, pharmacy services to the hospital were provided by staff from two different acute hospital trusts. Restructuring then took place and the Sussex Downs and Weald PCTs community health services pharmacy team was set up to provide clinical and technical pharmacy services to the community hospitals. The team consists of two senior pharmacy technicians and a pharmacist. Pharmacy technicians generally visit each hospital twice a week, reviewing drug charts for discrepancies (including missed allergy status information) and ordering medicines as appropriate.

When the PCT pharmacy team took over, we noticed that each of the community hospitals used a different drug prescription and administration chart. The charts in some hospitals allowed for 14 days administration only — the average patient stay is about six weeks — and there was not always a clear space for recording allergy status.

We thought that the design of drug charts may be contributing to the situation where allergy status was not always being recorded. We therefore redesigned the drug charts so that the same format was used at each of the hospitals and so that they were more suitable for long-stay patients, with a dedicated space for allergy status recording (highlighted by a red box). We also designed a patient-held medication record card, where there is provision for recording an allergy status.

Despite these changes, the pharmacy team were still finding that the allergy status boxes on drug charts were not always being filled in. It was therefore decided that we should carry out an audit to investigate the issue further.

Audit

One of my roles in the audit was to put together an audit plan and design a data collection form, following consultation with other team members.

The audit took place over four weeks. It included all patients recently admitted to the medical wards whose drug charts had not been previously checked by a member of the pharmacy team. If the allergy status of a patient was not recorded on the front of the drug charts, then the pharmacy team reviewed the community hospital’s medical notes, nursing kardex and acute trust notes to see if it was recorded elsewhere. If no record was found, other sources were used, such as the patient and his or her carers or the GP.

Data were collected for 54 patients. The results of the audit are set out in Panel 1. Of the 21 patients who did not have their allergy status recorded on the drug prescription and administration chart, four were found to have allergies. These were to:

· Penicillin (recorded on an old drug chart and on the nursing kardex)

· Non-steroidal anti-inflammatory drugs, aspirin and diazepam (recorded in the acute trust notes)

· Statins and sandoglobulin (recorded in the GP’s summary in the community hospital’s notes)

· Adhesive (recorded on an old drug chart)

Although there were incidences of allergy status not being recorded on drug charts in all four hospitals, there were variations in the frequency with which this occurred — from 20 to 50 per cent of admissions. Because the drug charts had been redesigned and were the same throughout the community hospitals, this discrepancy could no longer be the result of differences in charts used.

Implications

The four omissions in recording a known allergy set out above clearly had the potential to cause adverse events that could have serious consequences for patients. There might also have been financial implications for the PCT, such as those associated with an increased length of stay in hospital.

The audit results suggest that allergy status is not always recorded when patients are, for example, admitted from an acute trust hospital or when a new drug chart is needed.

It should be noted that as part of the service they offer, pharmacy technicians check that a patient’s allergy status is recorded before ordering any newly-prescribed medicines. If it is not recorded, they review, for example, the patient’s notes and nursing kardex and contact his or her GP if necessary. However, twice-weekly visits mean that there will be times when drugs are administered (for example, from stock) before a member of the pharmacy team has had the opportunity to carry out this review.

Improving practice

The first method we used to improve practice was to write an audit report, which was discussed with the matron at each of the community hospitals and with other senior managers. The report’s findings are about to be discussed at each hospital’s clinical governance meeting. By discussing the audit results, it is hoped that the issue of allergy status recording will be brought to the attention of all staff and that this will remind prescribers and ward nurses of their responsibilities to document and check a patient’s allergy status when prescribing and administering medicines.

The pharmacy team is also to write a standard operating procedure, with multidisciplinary input, for the documentation of drug allergy status. This will include details of the roles and responsibilities of the different health professionals involved in the medication process as stated in “Building a safer NHS for patients: improving medication safety.” We will also revisit the design of the drug charts, to see if the allergy section needs to be even more prominent so that prescribers remember to complete this information.

Since the audit report has been circulated to matrons and managers, members of the pharmacy team have noticed an improvement in allergy status recording. It is important to ensure that further audits take place, to establish whether this anecodotal evidence of improvement can be confirmed. I am therefore planning to repeat the allergy audit next year. Audits in subsequent years will be needed to establish whether the improvements achieved have been maintained.

Pharmacy technicians within community hospitals have an important role in contributing to the safe and secure handling of medicines including ensuring that the allergy status of patients are recorded, as this audit demonstrates. I am planning to conduct further studies including auditing all the drug fridges within the trust to ensure that these are being monitored correctly as stated in the (revised) Duthie Report.³

ACKNOWLEDGEMENT Thanks go to Iben Altman (principal pharmacist) and Maria Bonwick (senior pharmacy technician), the other members of the Sussex and Weald PCT community health services pharmacy team.

References

1. Department of Health. Building a safer NHS for patients; improving medication safety. London: The Department; 2004.

2. Nursing and Midwifery Council. Guidelines for the administration of medicines. London: The Council; 2004.

3. Royal Pharmaceutical Society. The safe and secure handling of medicines. A team approach (a revision of the Duthie Report 1988). London: The Society; 2005.