| Recommendations |
Documenting and sharing information with other healthcare professionals
Documenting new suspected drug allergic reactions
Maintaining and sharing drug allergy information
Documenting information after specialist drug allergy investigationsFor recommendations on referral to specialist services see Chapter 12 After specialist drug allergy investigations, allergy specialists should document:
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| Relative values of different outcomes | The following outcomes were identified by the GDG as important for decision-making: medication errors (inappropriate prescription or administration of drugs), number of repeat drug allergic reactions, inappropriate avoidance of drugs and quality of life. The first 2 were considered by the GDG to be the most important outcomes. Not all of the stated outcomes were found in the studies included. In general, most of the studies reported outcomes related to medication prescribing errors or adverse drug reactions, and not specifically to drug allergy. |
| Trade-off between clinical benefits and harms | The GDG noted a recent report by NHS England 130 which highlighted the high incidence of medication errors and agreed that errors in prescribing and administering drugs are a serious concern. The GDG observed that, at present, the labelling and coding used in electronic documentation systems do not enable such systems to differentiate between a side effect and an allergic reaction. It was agreed that if the information entered into such systems was of poor quality in the first instance then the output would also be of poor quality. The GDG considered that any system which allows accurate recording of information and prevention of erroneous prescription or administration of medications would be highly beneficial in improving patient safety. Studies related to computerised prescriber order entry (CPOE) systems showed very high rates of overriding of automated alerts (between 69% and 97%). The GDG indicated that once a patient has been diagnosed as having a drug allergy, this status would remain on the patient's record. Therefore, if a patient had previously been incorrectly diagnosed as having a drug allergy, the trigger alerts at subsequent visits to their physician would be overridden. Those studies that implemented a structured approach to documentation saw a reduction in medication prescribing errors and adverse drug reactions, and also an increase in healthcare professionals' compliance in completing patients' medical charts. The GDG therefore endorsed the application of structured documentation to record details of suspected drug allergies. |
| Economic considerations | No relevant economic evidence was identified. The GDG did not prioritise this question for original economic analysis. The GDG agreed that accurately documenting a person's current drug allergy status is vital in order to prevent inadvertent exposure to an allergen, and so to ensure patient safety. Whilst this may require an initial increase in healthcare professionals' time whilst current records are improved, in many cases this is likely only to bring forward a discussion that a GP will have with the person at some later point in time. The GDG were confident that any cost from increased numbers of GP consultations would be outweighed by increases in quality of life and costs saved due to future additional drug allergic reactions avoided. Similarly, accurate documentation of all new suspected allergic reactions to drugs will help identify appropriate future treatment, leading to better clinical outcomes and improved quality of life, at low cost. Documentation of reactions which are found not to be allergic reactions will reduce the unnecessary future avoidance of drugs and so reduce the usage of more expensive and potentially less effective alternatives. Accurate and sufficiently detailed recording of information regarding reactions at the time they are first reported will also reduce time spent later attempting to understand records relating to drug allergy which are unclear or unstructured. As noted above, there is a significant incidence of medication errors at the point of drug prescription and administration.130 Avoidable repeat reactions can have significant impact on the health and quality of life of people who experience them and will give rise to significant treatment costs; low cost methods of reducing these errors are therefore likely to be cost effective. Checking the drug allergy status of a person before prescribing them a drug would take a matter of seconds within the course of a normal GP consultation for a person whose status has already been systematically documented according to these recommendations and whose status is unchanged. In the same way, the GDG agreed it would take healthcare professionals who dispense and administer medication a few seconds more to read prescriptions including slightly more information and to confirm this with the patient. Although a short amount of additional time added to many thousands of GP consultations and occasions when drugs are administered could add up to a significant total, the GDG emphasised the importance of accurate documentation and information sharing between health services in reducing both avoidable repeat allergic reactions and the costs involved in treating those reactions. There is also a possibility that time would be saved in some cases where a patient is currently asked to explain their full allergy history on multiple occasions to those prescribing, dispensing or administering drugs who are currently not provided with sufficient allergy information, and so need to elicit the information afresh on each occasion. The GDG agreed that these strategies were therefore likely to be highly cost effective compared to current practice. |
| Quality of evidence | The studies included were predominantly observational studies from the USA and the electronic systems that they evaluated were designed and developed to suit the purpose of the study site. None of these systems can be directly compared with current or prospective systems in the UK. Importantly, most of the studies focused on rates of medication prescribing errors or adverse drug reactions in general, and data specific to drug allergy were minimal. The outcomes of the included studies varied considerably, with some documentation strategies leading to positive results whilst others led to less favourable effects. Positive findings from the implementation of computerised systems cannot necessarily be attributed to the system alone. It is possible that introduction of a new system itself raises awareness amongst the personnel working at the site, or that training that accompanies the system's introduction improves practice amongst healthcare professionals. The studies did not provide sufficient data on what training was provided with the computerised systems. Overall, although the studies observed a reduction in medication prescribing errors and adverse drug reactions, the evidence from these studies was varied and of very low quality. Therefore, the evidence did not enable the GDG to make recommendations on specific systems, and highlighted the need for further research. |
| Other considerations | The GDG noted that there is an increase in the use of computerised systems and a push towards paperless systems being introduced in the NHS . However, in the absence of evidence, it is not possible to make recommendations specifically for computerised systems. Nevertheless, the GDG recognised that the quality of the information recorded within any documentation system is paramount and concluded that having a well organised, structured system in any format would be very helpful in reducing the number of prescribing errors and preventing allergic reactions. Specifying the information that needs to be recorded and allocating specific locations for details of drug allergy to be recorded will serve to enhance the skills of healthcare professionals in taking medical histories and increase their compliance in completing patients' medication charts. Details on the type of information or the level of detail being documented in patient records were not described within the studies. The GDG drafted consensus recommendations on when drug allergy status should be recorded, the level of detail required and who this information should be shared with based on their own clinical experience, and recent publications that have highlighted areas of good practice.2 The GDG was aware that some hospitals already have prescription forms including drug allergy status, but that this was not currently part of GP or dentist standard prescription forms (FP10, HS21B). The group noted the current inequality this posed in the delivery of care between primary and secondary settings. Given the GDG's observation on the lack of communication between healthcare professionals in primary and secondary care and across different departments within hospitals, it is important to ensure that structured documentation is in place at all levels of patient care. The GDG agreed that most prescriptions are now generated electronically and therefore including information on a patient's drug allergy status is possible.. It was noted that community pharmacy has a role in minimising re-exposure to drugs where there is a known drug allergy, and having information on the prescription form would enable this and help improve patient safety. The GDG agreed that a review of systems, including prescription forms for recording drug allergy is required because current levels and methods of documentation are inadequate. To prevent the loss of information about a patient's drug allergy between contacts with healthcare providers, it is important that patients are given the necessary information and details of their own drug allergy status, and that such information is held by the patient and shared with their clinicians. Evidence and recommendations related to this issue can be found in Chapter 10 (Information and support). Guidance on medicines reconciliation on hospital admissions is available in NICE patient safety guidance 1 (PSG1). The guidance aims to lay out patient safety solutions to ensure that medicines prescribed on admission correspond to those that the patient was taking before admission. The GDG also noted the recent i-care report2 of the Academy of Medical Royal Colleges that highlighted the need for patient records to follow a standardised structure and content and to be available across organisational boundaries. The report's recommendation for a recognised nomenclature of clinical terms such as SNOMED to be used within the NHS was endorsed by the GDG. Computerised systems for patient records currently use a variety of different codes for drug allergy, and the GDG agreed implementation of a standard code and terminology would improve patient safety and management. |
From: 9, Documenting and sharing information with other healthcare professionals
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