Completeness and accuracy of adverse drug reaction documentation in electronic medical records at a tertiary care hospital in Australia

Abstract

Background: A large proportion of patients presenting to hospitals have experienced a previous adverse drug reaction (ADR). Electronic medical records (EMRs) present an opportunity to accurately document ADRs and alert clinicians against inadvertent rechallenge where there is a pre-existing reaction. However, EMR systems are imperfect and rely on the accuracy of the data entered. Objective: To ascertain the completeness of ADR documentation and the accuracy of the classification of ADRs as allergy versus intolerance in the EMR at a major metropolitan hospital in Australia. Method: Cross-sectional audit of the ADR field of the EMR for a sample of patients on four different wards over 3 weeks to ascertain the completeness of ADR documentation and the accuracy of classification of ADRs. Results: Of the 264 patients assessed, 102 (38.6%) had a total of 210 ADRs documented in the EMR. Of these, 105 (50%) were considered to have complete documentation; 63/210 (30.0%) were missing a reaction description and 88/210 (41.9%) were missing severity information. For those ADRs with a reaction description ( n = 147), 97 (66.0%) were considered to be appropriately classified as allergy or intolerance. Conclusion: Incomplete and inaccurate ADR documentation was common. These findings highlight a need for optimising ADR documentation to improve appropriate medication use in hospital. Implications: Improved EMR design and education of healthcare workers on the importance of complete and accurate documentation of reactions are needed to improve completeness and accuracy of ADR classification.

Communicating adverse drug events: serotonin toxicity

“…In a recent electronic medical record audit within an Australian tertiary care hospital, incomplete and inaccurate adverse drug event documentation was common. 20 Another Australian study found that one in eight older people hospitalised because of an adverse drug event had a repeat admission for an adverse drug event within 12 months. 21 A Canadian analysis from three multicentre observational studies in British Columbia found that 32.5% of adverse drug events identified in emergency departments were repeat events; of these, 75.3% were deemed preventable.…”

“…Poor documentation regarding adverse drug events is a known problem. In a recent electronic medical record audit within an Australian tertiary care hospital, incomplete and inaccurate adverse drug event documentation was common 20 . Another Australian study found that one in eight older people hospitalised because of an adverse drug event had a repeat admission for an adverse drug event within 12 months 21 .…”

Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management

“…These concerns were reflected in a number of articles. For example, Chen et al (2022) found that documentation of working diagnoses was highly variable among non-consultant grade clinicians, whereas McLachlan et al (2023) reported that incomplete and inaccurate documentation of adverse drug reactions was common in the hospital under study. Sierla and Dylke (2023) also noted inconsistencies in how data on lymphoedema were gathered and understood, proving a barrier to sharing and comparing data among clinicians.…”

“…Recommendations indicated that clinician education could be extended beyond initial training, be ongoing and encompass clinical classifications and coding standards . Education for other stakeholders included targeted training for CCs (Doktorchik et al, 2020;, together with CDI audits to monitor, raise awareness and provide feedback (Alonso et al, 2020;McLachlan et al, 2023). The importance of building strong professional relationships and communication is imperative for collaborative working in all CDI activities, according to Doktorchik et al (2020), and Pine et al (2023).…”

“…In their editorial on the emergence of health information in aged care, Loggie and Davis (2023) discussed needed improvements in clinical documentation related specifically to the aged care sector. Other recommended strategies to improve clinical documentation include the implementation of structured note templates, standardised terminology and the use of core datasets in diverse areas such as drug reactions (McLachlan et al, 2023), nutrition (Lövestam et al, 2020), stroke (Kilkenny et al, 2022), lymphoedema and hernia surgery .…”