P15: DRUG REPORTING ACCURACY AND COMPLETENESS IS DEPENDENT ON THOSE WHO ARE INVESTED IN NEGATIVE OUTCOMES OF ADVERSE DRUG REACTIONS

Abstract

It is widely observed that drug allergy documentation is often performed poorly. We hypothesised that there are different levels of compliance with drug allergy reporting in different modes of documentation within the same patient’s case notes. 76 medical records were from patients that were post-anaesthetic elective/emergency, medical/surgical inpatients in October 2016 were randomly audited. Allergy details were extracted from the standard medication charts, the Flinders Medical Centre Alert Sheet and Anaesthetic charts for these patients. Each were assessed for compliance with the Australian Commission on Safety and Quality in Health Care (ACSQHC) Standard 4 and the Clinical Procedure: Adverse Drug Reaction and Allergies Reporting Procedure (Flinders Medical Centre, 30 July 2014). Those that were deemed to be compliant had the name of drug (or documentation of ‘no allergy’), information describing drug reaction and details of the person recording the reaction. Anaesthetic charts were 79% compliant with standards. National Medication Charts (NIMC) 51% compliance and Alert Sheet reporting at 9% had the lowest compliance rates. In cases where information was incomplete, some had only drug listed, without reaction details or name of person documenting. Drug reporting can be performed by health professionals (HP’s) with accuracy, care and completeness. It appears that documentation appears to be of higher quality for those HP with a greater investment in direct administration of medication and or related to specialty knowledge of drug allergy, such as the risk of intra-operative anaphylaxis and reporting by anaesthetists. It is hypothesised that persons who are not authorised to document in the notes such as nursing staff, complete the relevant information as a way of preventing medication errors, but omit their name and title due to legal reasons.