Allergies and Alert Recording in a Tertiary Victorian Hospital: Paper and Electronic Health Records to Improve Patient Safety

Background: The current challenge within healthcare services is managing the transition from paper to electronic documentation and the associated process of change management. The recording of Allergies and alerts is an area of importance due to the direct impact to patient safety. Objectives: The objective of this paper is to describe and discuss the current benefits and limitations of a health informatics intervention as a quality activity. This approach was viewed as the most effective intervention for assessing the accuracy and clarity of recording allergies and alerts in medical records in a large Victorian Hospital in Australia. Methods: The method used for this health informatics intervention was a clinical audit tool. This method systematically allows the analysis of the quality of the recording, including the procedures used by healthcare professionals for communicating allergies and alerts in the medical record. This auditing tool consists of a list of primary elements to be assessed in the medical record; including the manner that healthcare professionals incorporate the allergies and alerts recording in paper based and electronic form. Elements included were the location of the allergies and alerts recording, consistency levels between recordings, allergies recording in admission/discharge forms, synchronised recording between documents and discrepancies between the location of recordings. At the time when this paper was written there were nearly 100 medical records analysed for its purposes. Results: The findings of this health informatics intervention suggest some minor and major inconsistencies with recording allergies and alerts between the paper-based records and electronic systems. The level of utilisation of the hospital clinical alerts form was poorly sustained and recording of allergy status was most commonly documented in the medication charts. Discussion: Recording appropriate allergies and alerts are critical for ensuring a clear communication process among healthcare professionals and to ensure patient safety. Conclusion: This health informatics intervention provided an effective assessment of the current state of recording allergies and alerts in a large Victorian hospital, using a quality improvement activity, and consequently, providing recommendations to develop accurate and feasible policies.