title: Drug allergy documentation--time for a change?
abstract: OBJECTIVE
  To audit patients' allergy documentation in a large rural hospital an to make recommendations about accurate drug allergies in hospital settings.
  
  
  METHODS
  A 257 bed large hospital and fully integrated health service in Australia, providing a range of services including; medicine, surgery, aged care, cancer care, mental health, maternity and rehabilitation.
  
  
  METHODS
  A retrospective design was used to fulfil the aims of this study. Patient medical records were randomly selected and checked for allergy documentation over a 6 month period.
  
  
  RESULTS
  A total of 521 patients' medical records were reviewed. Of all the medical records examined in total, 269 (52%) had no allergy, while 252 (48%) reported some kind of allergy. Overall, only three patients (0.6%) had their allergy details fully and accurately recorded in the three places audited and they are the front cover of the patients' notes, the admission notes and the drug chart.
  
  
  CONCLUSIONS
  Many preventable medical errors are caused by poor documentation which is often due to lack of drug allergy information. All health professional should be more pro-active in determining the manner of any drug allergy or adverse drug reactions (ADR) along with the extent of the reaction.
authors: Faculty of Medicine, Nursing and Health Sciences, School of Rural Health, Monash University, Ollerton Rd, Moe, VIC 3825, Australia. hanan.khalil@med.monash.edu
authors: Hanan
authors: H
authors: Khalil
authors: Anne
authors: A
authors: Leversha
authors: Viviane
authors: V
authors: Khalil
references: JAMA. 1995 Jul 5;274(1):29-34
references: 7791255
references: Am J Health Syst Pharm. 1997 Jul 15;54(14):1627-9
references: 9248608
references: Am J Health Syst Pharm. 1996 Dec 15;53(24):2970-5
references: 8974160
references: Ir J Med Sci. 2008 Sep;177(3):243-5
references: 18560922
references: JAMA. 1997 Jan 22-29;277(4):312-7
references: 9002494
references: J Nurs Care Qual. 2007 Oct-Dec;22(4):322-7
references: 17873729
references: Am J Health Syst Pharm. 2008 Jun 15;65(12):1177-9
references: 18541689
references: J Emerg Nurs. 2009 Jun;35(3):239-41
references: 19446132
references: J Eval Clin Pract. 2007 Feb;13(1):130-7
references: 17286735