Objectives To audit the documentation of allergy status on inpatient paediatric drug charts. To raise an awareness of the importance of this essential documentation when prescribing, pharmacist screening and administering drugs.
Methods A 2007 NPSA report states that patients being given medicine to which they were known to be allergic accounted for 3.2% of all medication incidents reported; 33% of these resulted in harm and 5% in severe harm or death.1 It follows that where allergy status is not documented, the risk of harm to the patient is higher and therefore Trust standards require that 100% of drug charts have the allergy status documented before any medicine is prescribed or administered.2 3 Prospective data collection took place 1 day each week over a 10 week period from March 2010, and again from July 2011. Data were collected on Monday mornings before the pharmacist had been to the ward as it was assumed that the pharmacist would ensure 100% completion. Data were also collected relating to whether the chart had been seen at any point by a pharmacist. The new inpatient drug chart was launched at the end of 2010. It includes a cut out window on each page so that the allergy status can be seen on every page and the lines in the allergy box were removed to create more white space and counter the cluttered appearance of the previous drug chart. Feedback from the first audit was presented at the departmental audit meeting on the 5th July 2010. All data were analysed using Microsoft Excel.
Results 2010 results: 280 (80%) of 350 charts were seen over a 10 week period. Of these, 84 (30%) did not have the allergy status documented. Of the 280 charts analysed, 134 (48%) had been seen by a pharmacist and 8 (6%) of these still had no allergy status documented. 146 (52%) of charts had not yet been seen by a pharmacist and 37 (25%) of this group had no allergy status documented.
Conclusion The standard of 100% was not met; even after pharmacist screening. Awareness needs to be raised concerning allergy status and documentation thereof. It should be an integral part of the prescribing and screening process to ensure safe delivery of medicines. It is hoped that the changes to the drug chart will have improved the documentation.