Please use this identifier to cite or link to this item: https://ahro.austin.org.au/austinjspui/handle/1/32919
Title: Completeness and accuracy of adverse drug reaction documentation in electronic medical records at a tertiary care hospital in Australia.
Austin Authors: McLachlan, Gina ;Broomfield, Airley;Elliott, Rohan 
Affiliation: Pharmacy
Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia.
Issue Date: May-2023
Date: 2021
Publication information: Health Information Management : Journal of the Health Information Management Association of Australia 2023
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.
URI: https://ahro.austin.org.au/austinjspui/handle/1/32919
DOI: 10.1177/18333583211057741
ORCID: 0000-0002-7122-164X
0000-0002-7750-9724
Journal: Health Information Management : Journal of the Health Information Management Association of Australia
Start page: 108
End page: 111
PubMed URL: 34930047
ISSN: 1833-3575
Type: Journal Article
Subjects: adverse drug reactions
documentation
electronic health record
hospitals
patient safety
Drug-Related Side Effects and Adverse Reactions/epidemiology
Appears in Collections:Journal articles

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