Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Comparison of
documentation of patient
reported adverse drug
reactions on both paper-
based medication charts and
electronic medication charts
at a New Zealand hospital
Wilson Shen, Bernice Wong, Jessica Yi Ping Chin, Michael Lee, Carolyn
Coulter, Rhiannon Braund
ABSTRACT
AIM: Known adverse drug reactions (ADRs) can have profound effects on disease states, as well as
prescribing practice. Therefore, the correct and complete documentation of each individual patient’s ADR
history, upon hospital admission, is important in optimising that individual patient’s pharmacotherapy.
This study investigated the documentation of ADRs at a tertiary New Zealand hospital, on both paper-
based medication charts and electronic medication charts to quantify both the number of ADRs patients
self-report, as well as the differences between recording of that information in electronic and paper-based
charting systems.
METHOD: Following ethical approval, inpatient medication charts on the general medical ward (electronic
prescribing), or the general surgical ward (paper-based medication charts) were viewed for documented
ADRs—as reported by each patient on admission. Consecutive patient charts (and electronic clinical
management system) were viewed until 50 patients from each ward, each with at least one documented
ADR, (in any of the information sources) were obtained. Patient demographic information, ADR history and
discrepancies between information sources were determined.
RESULTS: In both wards 114 patients were reviewed in order to find 50 patients with documented ADRs.
In the medical ward (electronic) 44 (90%) patients had discrepancies in ADR information between different
information sources and in the surgical ward (paper) this occurred in 49 (98%) patients.
CONCLUSION: A large number of patients self-report ADRs. Full documentation of patient reported ADRs
is required to adequately inform future prescribing decisions. Discrepancies between ADR information
recorded in different information systems exist, but information sharing between electronic and
non-electronic sources could be prioritised in order to allow full and complete information to be collected,
stored and utilised; and reduce the current inadequacies.
The correct documentation of a history of [for] therapy of disease”1–2 and can span
true immune-mediated allergic reactions to from mild annoyances, such as indigestion,
medications can play an important role in to medical emergencies including anaphy-
the decision making process of prescribing laxis. ADRs are often poorly understood by
for that patient’s current condition. ADRs patients leading to both over and under-re-
are defined by WHO as “a response to a porting, and are often misdiagnosed and
drug that is noxious and unintended which incompletely categorised by doctors and
occurs at doses normally used in man … other healthcare professionals, both which
92
NZMJ 28 October 2016, Vol 129 No 1444
ISSN 1175-8716 © NZMA
Te Hauora mō ngā Iwi Katoa
www.nzma.org.nz/journal
ARTICLE
93
NZMJ 28 October 2016, Vol 129 No 1444
ISSN 1175-8716 © NZMA
Te Hauora mō ngā Iwi Katoa
www.nzma.org.nz/journal
ARTICLE
CMS, irrespective of which ward they are documented, the patient was excluded. This
admitted to and the prescribing system used. process was continued until 50 patients from
There are several ways that ADRs may be each specialty area (surgical or medical)
recorded; 1) hand written onto the paper- were included in the study.
based medication chart; 2) entered into the Demographic information such as gender,
EPSS; 3) entered into the CMS system as part age and the number of documented ADRs for
of patient notes; or 4) CMS can “import” ADR each patient was recorded. Where possible,
information from the EPSS—however, the the implicated drug or drug class was
synchronicity of information between these recorded, and where documented, the mani-
two electronic systems is not always complete. festation of the ADR. Additionally, the date of
ADRs may be recorded from the patient the ADR was recorded (if documented).
self-reporting these at time of admission, or Identification of discrepancies occurred
from clinicians accessing previous records when agents and associated reactions were
(electronic and paper based). not the same in each information source.
Data collection These discrepancies occurred because one
Following ethical approval, medication information source may have stated the
charts from patients on the two general agent, whereas the other source may have
surgical wards (that use paper-based had the agent and the level of reaction (or
prescribing charts) were viewed and medi- even the date). Discrepancies like these
cation charts from patients on the two meant that completeness of information
general medical wards (that use electronic viewed depended on the information
prescribing) were viewed. The ADR infor- source used by the clinician. For patients
mation from each patient chart was recorded who had discrepancies, the information
and the ADR information for each patient source with the highest quantity of infor-
was subsequently reviewed on the CMS. mation was determined (by comparison of
the information) and identification of the
If any of the information sources had one
source that provided the largest number
or more ADRs documented, the patient was
of reported ADRs. ADRs reported were not
included in the study, but if no information
independently investigated and verified for
was documented in any of these sources
accuracy during the study.
or ‘no known drug allergies’ or ‘NKDA’ was
Figure 1: Age distribution of patients with ADRs from the medical () and surgical wards ().
94
NZMJ 28 October 2016, Vol 129 No 1444
ISSN 1175-8716 © NZMA
Te Hauora mō ngā Iwi Katoa
www.nzma.org.nz/journal
ARTICLE
Figure 2: Number of medication classes implicated in ADRs from patients in the medical () and surgi-
cal wards ().
95
NZMJ 28 October 2016, Vol 129 No 1444
ISSN 1175-8716 © NZMA
Te Hauora mō ngā Iwi Katoa
www.nzma.org.nz/journal
ARTICLE
Penicillins 25 26
Cephalosporins 7 1
Sulfur-containing antibiotics 5 1
Other antibiotics 9 11
Opioids 9 6
NSAIDs 7 9
ACE inhibitors 2 2
Diuretics 2 1
Other medicines 26 30
Non-drug allergy* 7 8
Total 102 95
*Includes foods, sticking plasters.
Anaphylaxis 6 7
Misc GI upset* 3 8
Swelling or angioedema 6
Headache 5
GI bleed* 4
Hypertension 4
Fever 4
Flushing 2 2
Shortness of breath 3
Cough 3
‘Unwell’ 3
Diarrhoea 3
Palpitations/tachycardia 3
Asthma/bronchospasm 2
Tight chest 2
Other 14 14
Total 86 68
*GI = gastrointestinal
*Misc = miscellaneous
96
NZMJ 28 October 2016, Vol 129 No 1444
ISSN 1175-8716 © NZMA
Te Hauora mō ngā Iwi Katoa
www.nzma.org.nz/journal
ARTICLE
97
NZMJ 28 October 2016, Vol 129 No 1444
ISSN 1175-8716 © NZMA
Te Hauora mō ngā Iwi Katoa
www.nzma.org.nz/journal
ARTICLE
Competing interests:
Nil.
Acknowledgements:
The authors wish to thank the staff at the study hospital for their assistance with data access
and collection.
Author information:
Wilson Shen, School of Pharmacy, University of Otago, Dunedin; Bernice Wong, School of
Pharmacy, University of Otago, Dunedin; Jessica Yi Ping Chin, School of Pharmacy, University
of Otago, Dunedin; Michael Lee, School of Pharmacy, University of Otago, Dunedin; Carolyn
Coulter, Pharmacy Department, Dunedin Hospital, Dunedin; Rhiannon Braund, Associate Pro-
fessor, School of Pharmacy, University of Otago, Dunedin.
Corresponding author:
Rhiannon Braund, Associate Professor, School of Pharmacy, University of Otago, Dunedin.
rhiannon.braund@otago.ac.nz
URL:
http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1444-
28-october-2016/7051
REFERENCES:
1. Radford A, Undre S, 6. Khalil H, Leversha A, cians’ experiences using
Alkhamesi NA, et al. Khalil, V. Drug allergy commercial e-prescribing
Recording of drug documentation—time systems. Health Affairs.
allergies: are we doing for a change? Int J Clin 2007; 26:393–404.
enough? J Eval Clin Pharm. 2011; 33:610–613. 11. Kaushal R, Kern LM,
Pract. 2007; 13:130–137.
7. Turner RD. (2006) Are Barron Y, et al. Electronic
2. Edwards IR, Aronson JK. we aware of hospital prescribing improves
Adverse drug reactions: patients’ drug allergies? medication safety in
definitions, diagnosis, J Clin Pharm Ther. community-based office
and management. Lancet.
2006; 31:649–650. practices. J Gen Intern
2000; 356:1255–1259.
8. The American Medical Med. 2010; 25:530–536.
3. Sastre J, Manso L,
Association. The physi- 12. Nebeker JR, Hoffman JM,
Sanchez-Garcia S, et al.
cians role in medicines Weir CR, et al. High rates
Medical and economic
reconciliation—issues, of adverse drug events
impact of misdiagnosis
of drug hypersensitivity strategies and safety in a highly computerized
in hospitalized patients. principles. https://bcpsqc. hospital. Arch Int Med.
J Allergy Clin Immunol. ca//documents/2012/09/ 2005; 165:1111–1116.
2012; 129:566–567. AMA-The-physi- 13. Gomes ER, Demoly P.
cian%E2%80%99s-role- Epidemiology of hyper-
4. Picard M, Begin P, Bouch-
ard H, et al. Treatment in-Medication-Recon- sensitivity drug reactions.
of patients with a history ciliation.pdf. [accessed Curr Opin Allergy Clin
of penicillin allergy in 20 Sept 2014]. Immunol. 2005; 5:309–316.
a large tertiary-care 9. Health Safety and Quality 14. Ash JS, Berg M, Coiera
academic hospital. J Commission New Zealand. E. Some unintended
Allergy Clin Immunol Medicines Reconciliation. consequences of infor-
Pract. 2013; 1:252–257. http://www.hqsc.govt.nz/ mation technology in
5. Jones TA, Como JA. our-programmes/medi- health care: the nature of
Assessment of medication cation-safety/projects/ patient care information
errors that involved drug medicine-reconciliation/. system-related errors. J
allergies at a university [accessed 20 Sept 2014]. Am Med Inform Assoc.
hospital. Pharmacother-
10. Grossman JM, Gerland 2004; 11:104–112.
apy. 2003; 237:855–860.
A, Reed MC, et al. Physi-
98
NZMJ 28 October 2016, Vol 129 No 1444
ISSN 1175-8716 © NZMA
Te Hauora mō ngā Iwi Katoa
www.nzma.org.nz/journal