Action 4.7 states

The health service organisation has processes for documenting a patient’s history of medicine allergies and adverse drug reactions in the healthcare record on presentation

Intent

Medicine-related risks for patients are minimised by documenting and referring to the patient’s history of medicine allergies and adverse drug reactions (ADRs).

Reflective questions

How does the health service organisation ensure that a patient’s history of medicine allergies and ADRs is recorded when taking a best possible medication history (BPMH) on presentation?

How do clinicians who prescribe, dispense or administer medicines know that a patient has an existing medicine allergy or ADR?

Key task

Document known patient medicine allergies and ADRs on presentation, and make this information available when clinicians prescribe, dispense and administer medicines.

Strategies for improvement

Hospitals

As part of a BPMH, clinicians must elicit and document known medicine allergies and ADRs experienced by a patient before their current admission (see Actions 4.5 and 4.6).

Review organisational policies, procedures and guidelines on recording known medicine allergies and ADRs in the patient’s healthcare record. These should:

  • Identify the clinician responsible for recording information on known medicine allergies and ADRs
  • Outline what information to include (for example, type of reaction experienced, its severity, how it was managed)
  • Describe what action should be taken if the nature of the documented reaction needs to be challenged or verified (for example, as a result of immunologist consultation), including instances of allergy mismatch
  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband
  • Describe where and when it is appropriate to record a known allergy or adverse reaction to substances other than medicines, such as food, in the patient’s medicine allergy and ADR history.

Ensure that known medicine allergies and ADRs are recorded:

  • In the medication history (paper or electronic)
  • On all forms on which medicines are ordered, such as national standard medication charts, ancillary charts and the anaesthesia record
  • In electronic medication management and dispensing systems
  • On ADR summary sheets or similar
  • By using an alert sticker on hard-copy healthcare records
  • By using electronic allergy/ADR alerts in digital healthcare records.

Provide orientation, training and education to clinicians, and review clinician work practices for:

  • Determining and documenting known medicine allergies and ADRs in the patient’s medicine allergy/ADR history, including the type of reaction, the severity and how it was managed
  • Referring to a patient’s medicine allergy/ADR history before, or at the point of, decision-making when prescribing, dispensing or administering medicines.

Conduct audits of documentation on medicine allergies and ADRs. These may focus on patients who have experienced previous medicine allergies or ADRs, the information that has been documented and where it has been documented (for example, in the medication chart, MMP or equivalent, discharge summary, medicines list, electronic medication management system). Data could be collected during an audit of the NIMC (linked to Action 4.8).

Collate and review audit trends, and provide information to clinicians through medication safety bulletins, in-service orientation sessions, case reports or grand rounds.

Day Procedure Services

As part of a BPMH, clinicians must elicit and document known medicine allergies and ADRs experienced by a patient before their admission (see Actions 4.5 and 4.6).

Review organisational policies, procedures and guidelines on recording known medicine allergies and ADRs in the patient healthcare record. These should:

  • Identify the clinician responsible for recording information on known medicine allergies and ADRs
  • Outline what information to include (for example, type of reaction experienced, its severity, how it was managed)
  • Describe what action should be taken if the nature of the documented reaction needs to be challenged or verified (for example, as a result of immunologist consultation), including instances of allergy mismatch
  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband
  • Determine where and when it is appropriate to record a known allergy or adverse reaction to substances other than medicines, such as food, in the patient’s medicine allergy and ADR history.

Ensure that medicine allergies and ADRs are recorded:

  • In the medication history (paper or electronic)
  • On all forms on which medicines are ordered, such as national standard medication charts, ancillary charts and the anaesthesia record
  • In electronic medication management and dispensing systems
  • On ADR summary sheets or similar
  • By using an alert sticker on hard-copy healthcare records
  • By using electronic allergy/ADR alerts in digital healthcare records.

Provide orientation, training and education to clinicians, and review clinician work practices for:

  • Determining and documenting known medicine allergies and ADRs in the patient’s medicine allergy/ADR history, including the type of reaction, the severity and how it was managed
  • Referring to a patient’s medicine allergy/ADR history before, or at the point of, decision-making when prescribing, dispensing or administering medicines.

Conduct audits of documentation on medicine allergies and ADRs. These may focus on patients who have experienced previous medicine allergies or ADRs, the information that has been documented and where it has been documented (for example, in the medication chart, MMP or equivalent, discharge summary, medicines list, electronic medication management system) (linked to Action 4.8).

Collate and review audit trends, and provide information to clinicians through medication safety bulletins, in-service orientation sessions or case reports.

Examples of evidence

Select only examples currently in use:

  • Policy documents about recording a patient’s known medicine allergies and ADRs on presentation
  • Audit results of healthcare records for documentation of known medicine allergies and ADRs on presentation
  • Feedback to the workforce about compliance with documenting known medicine allergies and ADRs on presentation
  • Training documents about taking and documenting a patient’s history of medicine allergies and ADRs on presentation.

MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established process for documenting a patient’s history of medicine allergies and ADRs, as a component of a BPMH (see Actions 4.5 and 4.6).

Small hospitals that are not part of a local health network or private hospital group should:

  • Develop or review policies, procedures and guidelines about recording known medicine allergies and ADRs in the patient healthcare record (paper or electronic) and on the MMP or equivalent
  • Ensure that known medicine allergies and ADRs are recorded on all forms on which medicines are ordered
  • Ensure that known medicine allergies and ADRs are recorded within electronic medication management systems and within dispensing systems
  • Provide orientation, training and education to clinicians
  • Review clinician work practices for determining and documenting known medicine allergies and ADRs, and referring to a patient’s medicine allergy and ADR history before and at the point of decision-making when prescribing, dispensing or administering medicines
  • Conduct audits of documentation of medicine allergies and ADRs
  • Collate and review audit trends, and provide information to clinicians through medication safety bulletins, in-service orientation sessions, case reports or grand rounds.

Hospitals

As part of a BPMH, clinicians must elicit and document known medicine allergies and ADRs experienced by a patient before their current admission (see Actions 4.5 and 4.6).

Review organisational policies, procedures and guidelines on recording known medicine allergies and ADRs in the patient’s healthcare record. These should:

  • Identify the clinician responsible for recording information on known medicine allergies and ADRs
  • Outline what information to include (for example, type of reaction experienced, its severity, how it was managed)
  • Describe what action should be taken if the nature of the documented reaction needs to be challenged or verified (for example, as a result of immunologist consultation), including instances of allergy mismatch
  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband
  • Describe where and when it is appropriate to record a known allergy or adverse reaction to substances other than medicines, such as food, in the patient’s medicine allergy and ADR history.

Ensure that known medicine allergies and ADRs are recorded:

  • In the medication history (paper or electronic)
  • On all forms on which medicines are ordered, such as national standard medication charts, ancillary charts and the anaesthesia record
  • In electronic medication management and dispensing systems
  • On ADR summary sheets or similar
  • By using an alert sticker on hard-copy healthcare records
  • By using electronic allergy/ADR alerts in digital healthcare records.

Provide orientation, training and education to clinicians, and review clinician work practices for:

  • Determining and documenting known medicine allergies and ADRs in the patient’s medicine allergy/ADR history, including the type of reaction, the severity and how it was managed
  • Referring to a patient’s medicine allergy/ADR history before, or at the point of, decision-making when prescribing, dispensing or administering medicines.

Conduct audits of documentation on medicine allergies and ADRs. These may focus on patients who have experienced previous medicine allergies or ADRs, the information that has been documented and where it has been documented (for example, in the medication chart, MMP or equivalent, discharge summary, medicines list, electronic medication management system). Data could be collected during an audit of the NIMC (linked to Action 4.8).

Collate and review audit trends, and provide information to clinicians through medication safety bulletins, in-service orientation sessions, case reports or grand rounds.

Day Procedure Services

As part of a BPMH, clinicians must elicit and document known medicine allergies and ADRs experienced by a patient before their admission (see Actions 4.5 and 4.6).

Review organisational policies, procedures and guidelines on recording known medicine allergies and ADRs in the patient healthcare record. These should:

  • Identify the clinician responsible for recording information on known medicine allergies and ADRs
  • Outline what information to include (for example, type of reaction experienced, its severity, how it was managed)
  • Describe what action should be taken if the nature of the documented reaction needs to be challenged or verified (for example, as a result of immunologist consultation), including instances of allergy mismatch
  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband
  • Determine where and when it is appropriate to record a known allergy or adverse reaction to substances other than medicines, such as food, in the patient’s medicine allergy and ADR history.

Ensure that medicine allergies and ADRs are recorded:

  • In the medication history (paper or electronic)
  • On all forms on which medicines are ordered, such as national standard medication charts, ancillary charts and the anaesthesia record
  • In electronic medication management and dispensing systems
  • On ADR summary sheets or similar
  • By using an alert sticker on hard-copy healthcare records
  • By using electronic allergy/ADR alerts in digital healthcare records.

Provide orientation, training and education to clinicians, and review clinician work practices for:

  • Determining and documenting known medicine allergies and ADRs in the patient’s medicine allergy/ADR history, including the type of reaction, the severity and how it was managed
  • Referring to a patient’s medicine allergy/ADR history before, or at the point of, decision-making when prescribing, dispensing or administering medicines.

Conduct audits of documentation on medicine allergies and ADRs. These may focus on patients who have experienced previous medicine allergies or ADRs, the information that has been documented and where it has been documented (for example, in the medication chart, MMP or equivalent, discharge summary, medicines list, electronic medication management system) (linked to Action 4.8).

Collate and review audit trends, and provide information to clinicians through medication safety bulletins, in-service orientation sessions or case reports.

Examples of evidence

Select only examples currently in use:

  • Policy documents about recording a patient’s known medicine allergies and ADRs on presentation
  • Audit results of healthcare records for documentation of known medicine allergies and ADRs on presentation
  • Feedback to the workforce about compliance with documenting known medicine allergies and ADRs on presentation
  • Training documents about taking and documenting a patient’s history of medicine allergies and ADRs on presentation.

MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established process for documenting a patient’s history of medicine allergies and ADRs, as a component of a BPMH (see Actions 4.5 and 4.6).

Small hospitals that are not part of a local health network or private hospital group should:

  • Develop or review policies, procedures and guidelines about recording known medicine allergies and ADRs in the patient healthcare record (paper or electronic) and on the MMP or equivalent
  • Ensure that known medicine allergies and ADRs are recorded on all forms on which medicines are ordered
  • Ensure that known medicine allergies and ADRs are recorded within electronic medication management systems and within dispensing systems
  • Provide orientation, training and education to clinicians
  • Review clinician work practices for determining and documenting known medicine allergies and ADRs, and referring to a patient’s medicine allergy and ADR history before and at the point of decision-making when prescribing, dispensing or administering medicines
  • Conduct audits of documentation of medicine allergies and ADRs
  • Collate and review audit trends, and provide information to clinicians through medication safety bulletins, in-service orientation sessions, case reports or grand rounds.