Action 4.8 states

The health service organisation has processes for documenting adverse drug reactions experienced by patients during an episode of care in the healthcare record and in the organisation-wide incident reporting system

Intent

Medicine allergies and ADRs experienced by patients while in the health service organisation are documented in the patient's medicine allergy/ADR history and in incident management and investigation systems.

Reflective questions

What processes are used to ensure that all medicine allergies and ADRs experienced by a patient during an episode of care are recorded in the patient’s healthcare record, and reported in the incident management and investigation system?

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

What processes are used to ensure that clinicians document a patient’s new medicine allergies or ADRs on their medicines list?

Key task

Document and report medicine allergies and ADRs experienced by patients during their episode of care (see Actions 4.1 and 4.2).

Strategies for improvement

Hospitals

Document all new medicine allergies and ADRs by including them in the patient’s existing history of medicine allergies and ADRs, to ensure that clinicians are alerted and can refer to this information when medicines are being prescribed, dispensed or administered.

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

  • Identify the clinician responsible for managing and recording information on new medicine allergies and ADRs

  • Ensure that all new medicine allergies and ADRs are reported within the organisation’s incident management and investigation system

  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband

  • Emphasise the importance of informing the patient about all new medicine allergies and ADRs, and informing other prescribers and members of their healthcare team

  • Incorporate information on new allergies and ADRs at care transfer and handover

  • Update the patient’s medicines list (linked to Action 4.12)

  • Inform the patient’s general practitioner and other members of the patient’s healthcare team (for example, community pharmacist) of all new medicine allergies and ADRs in the patient’s transfer or discharge summary.

Ensure that new medicine allergies and ADRs are recorded in the organisation's incident reporting system and:

  • 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:

  • Documenting and incorporating new 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.

Audit documentation on medicine allergies and ADRs. These may include the medication chart, the MMP or equivalent, or the electronic medication management system. Data could be collected during an audit of the NIMC (linked to Action 4.7).

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

Day Procedure Services

Document all new medicine allergies and ADRs by including them in the patient’s existing history of medicine allergies and ADRs, to ensure that clinicians are alerted and can refer to this information when medicines are being prescribed, dispensed or administered.

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

  • Identify the clinician responsible for managing and recording information on new medicine allergies and ADRs
  • Ensure that all new medicine allergies and ADRs are reported within the organisation’s incident management and investigation system
  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband
  • Emphasise the importance of informing the patient about all new medicine allergies and ADRs, and informing other prescribers and members of their healthcare team
  • Incorporate information on new allergies and ADRs at care transfer and handover
  • Update the patient’s medicines list (linked to Action 4.12)
  • Inform the patient’s general practitioner and other members of the patient’s healthcare team (for example, community pharmacist) of all new medicine allergies and ADRs in the patient’s transfer or discharge summary.

Ensure that new medicine allergies and ADRs are recorded in the organisation’s incident reporting system and:

  • 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:

  • Documenting new medicine allergies and ADRs in the patient’s medicine allergies/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.

Audit documentation on medicine allergies and ADRs. These may include the medication chart, the MMP or equivalent, or the electronic medication management system. Data could be collected during an audit of the NIMC (linked to Action 4.7).

Collate and review trends in reported medicine allergies and audit results, 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 new medicine allergies and ADRs experienced during an episode of care
  • Audit results of workforce compliance with policies, procedures, protocols and guidelines for documenting new medicine allergies and ADRs
  • Audit results of healthcare records for documentation of new medicine allergies and ADRs in places noted in policies, procedures, protocols and guidelines
  • Feedback to the workforce about compliance with policies, procedures, protocols and guidelines for documenting new medicine allergies and ADRs
  • Results of analysis of incident data relating to new medicine allergies and ADRs
  • Orientation or training documents about documenting patients’ new medicine allergies and ADRs.

MPS & Small Hospitals

MPSs and small hospitals should have policies and procedures about documenting and reporting medicine allergies and ADRs experienced by patients during their episode of care (see Action 4.1 and 4.2).

Processes for documenting medicine allergies and ADRs should:

  • Identify the clinician responsible for managing and recording information on new medicine allergies and ADRs
  • Describe how to report new medicine allergies and ADRs in the organisation’s incident management and investigation system
  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband
  • Emphasise the importance of informing the patient about all new medicine allergies and ADRs, and informing other prescribers and members of their healthcare team
  • Incorporate information on new allergies and ADRs at care transfer and handover
  • Update the patient’s medicines list (see Action 4.12)
  • Inform the patient’s general practitioner and other members of the patient’s healthcare team (for example, community pharmacist) of all new medicine allergies and ADRs in the patient’s transfer or discharge summary.

Ensure that new medicine allergies and ADRs are recorded in the organisation’s incident reporting system and:

  • In the medication history (paper or electronic)
  • On all forms on which medicines are ordered, such as national standard medication 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 relating to documenting medicine allergies and ADRs.

Audit documentation on medicine allergies and ADRs. These may include the medication chart, the MMP or equivalent, or the electronic medication management system (see Action 4.7).

Collate and review trends in reported medicine allergies and audit results, and provide information to clinicians.

Hospitals

Document all new medicine allergies and ADRs by including them in the patient’s existing history of medicine allergies and ADRs, to ensure that clinicians are alerted and can refer to this information when medicines are being prescribed, dispensed or administered.

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

  • Identify the clinician responsible for managing and recording information on new medicine allergies and ADRs

  • Ensure that all new medicine allergies and ADRs are reported within the organisation’s incident management and investigation system

  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband

  • Emphasise the importance of informing the patient about all new medicine allergies and ADRs, and informing other prescribers and members of their healthcare team

  • Incorporate information on new allergies and ADRs at care transfer and handover

  • Update the patient’s medicines list (linked to Action 4.12)

  • Inform the patient’s general practitioner and other members of the patient’s healthcare team (for example, community pharmacist) of all new medicine allergies and ADRs in the patient’s transfer or discharge summary.

Ensure that new medicine allergies and ADRs are recorded in the organisation's incident reporting system and:

  • 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:

  • Documenting and incorporating new 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.

Audit documentation on medicine allergies and ADRs. These may include the medication chart, the MMP or equivalent, or the electronic medication management system. Data could be collected during an audit of the NIMC (linked to Action 4.7).

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

Day Procedure Services

Document all new medicine allergies and ADRs by including them in the patient’s existing history of medicine allergies and ADRs, to ensure that clinicians are alerted and can refer to this information when medicines are being prescribed, dispensed or administered.

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

  • Identify the clinician responsible for managing and recording information on new medicine allergies and ADRs
  • Ensure that all new medicine allergies and ADRs are reported within the organisation’s incident management and investigation system
  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband
  • Emphasise the importance of informing the patient about all new medicine allergies and ADRs, and informing other prescribers and members of their healthcare team
  • Incorporate information on new allergies and ADRs at care transfer and handover
  • Update the patient’s medicines list (linked to Action 4.12)
  • Inform the patient’s general practitioner and other members of the patient’s healthcare team (for example, community pharmacist) of all new medicine allergies and ADRs in the patient’s transfer or discharge summary.

Ensure that new medicine allergies and ADRs are recorded in the organisation’s incident reporting system and:

  • 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:

  • Documenting new medicine allergies and ADRs in the patient’s medicine allergies/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.

Audit documentation on medicine allergies and ADRs. These may include the medication chart, the MMP or equivalent, or the electronic medication management system. Data could be collected during an audit of the NIMC (linked to Action 4.7).

Collate and review trends in reported medicine allergies and audit results, 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 new medicine allergies and ADRs experienced during an episode of care
  • Audit results of workforce compliance with policies, procedures, protocols and guidelines for documenting new medicine allergies and ADRs
  • Audit results of healthcare records for documentation of new medicine allergies and ADRs in places noted in policies, procedures, protocols and guidelines
  • Feedback to the workforce about compliance with policies, procedures, protocols and guidelines for documenting new medicine allergies and ADRs
  • Results of analysis of incident data relating to new medicine allergies and ADRs
  • Orientation or training documents about documenting patients’ new medicine allergies and ADRs.

MPS & Small Hospitals

MPSs and small hospitals should have policies and procedures about documenting and reporting medicine allergies and ADRs experienced by patients during their episode of care (see Action 4.1 and 4.2).

Processes for documenting medicine allergies and ADRs should:

  • Identify the clinician responsible for managing and recording information on new medicine allergies and ADRs
  • Describe how to report new medicine allergies and ADRs in the organisation’s incident management and investigation system
  • Include criteria for the appropriate use of a coloured (red) patient allergy/ADR wristband
  • Emphasise the importance of informing the patient about all new medicine allergies and ADRs, and informing other prescribers and members of their healthcare team
  • Incorporate information on new allergies and ADRs at care transfer and handover
  • Update the patient’s medicines list (see Action 4.12)
  • Inform the patient’s general practitioner and other members of the patient’s healthcare team (for example, community pharmacist) of all new medicine allergies and ADRs in the patient’s transfer or discharge summary.

Ensure that new medicine allergies and ADRs are recorded in the organisation’s incident reporting system and:

  • In the medication history (paper or electronic)
  • On all forms on which medicines are ordered, such as national standard medication 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 relating to documenting medicine allergies and ADRs.

Audit documentation on medicine allergies and ADRs. These may include the medication chart, the MMP or equivalent, or the electronic medication management system (see Action 4.7).

Collate and review trends in reported medicine allergies and audit results, and provide information to clinicians.