Accuracy and Documentation of Drug Allergies on Ward in a Cardiology Tertiary Care Unit (A Clinical Audit and Re-Audit)

Abstract

Objective: To assess whether status of allergies is accurately documented in clinical notes and drug prescription charts in two medical wards in Armed Forces Institute of Cardiology (AFIC) as compared to NICE guidelines. Study Design: We designed a classic audit of measuring current practice against guidelines. Place and duration of Study: Armed Force Institute of Cardiology/National Institute of Heart Disease (AFIC/NIHD), Rawalpindi Pakistan, from May to Oct 2020. Methodology: Each cycle contained of a two weeks’ period in which all new patients admitted in coronary care ward 3 and ward 10 were assessed. A total of 110 patients were assessed in each cycle. Repeat audit cycle was performed after 6 months similarly. Results: In first audit cycle, we assessed 110 patients. The status of allergies for most patients was recorded in clerking proforma (n=103, 93%) but there were deficiencies found in recording of allergies on drug kardex (n=25, 22%). After education and awareness, the second cycle showed that the status of allergies for all patients was recorded in clerking proforma (n=110, 100%) and documentation on drug kardex also improved from 22% to 78%. Conclusion: Repeat audit cycle showed significant improvement in documentation of allergies in clerking proforma and on drug kardex.

Keywords

• Allergy
• Clerking proforma
• Drug kardex