Recording previous adverse drug reactions - a gap in the system

Aims To measure the accuracy of recording of previous adverse drug reaction (ADR) history in patients admitted to a teaching hospital before and after an education programme. Methods One month survey of patients on one medical and one surgical ward, repeated after a 1 month education programme. Patients answered a questionn aire about previous ADRs and this information was compared with that in all relevant sections of their medical records and medication charts. Results Of 117 patients at baseline, 50 had a total of 81 previous ADRs. On ly 75% were recorded oil medication charts and 57% and 64%, respectively, i n medical and nursing notes. In the post education survey of 124 patients, 56 had 105 previous ADRs, 85% were recorded on medication charts and 64% an d 70% in medical and nursing records. These differences were not significan t. Serious ADRs were also poorly recorded at baseline but, due to intervent ion by ward pharmacists, their recording on medication charts improved sign ificantly after education. Pharmacists also significantly improved the qual ity of description of previous ADRs in both parts of the study. Conclusions Previous ADR history obtainable from hospital patients is poorl y recorded in medical records and an intensive education programme only pro duced a significant change in recording by ward pharmacists. Better strateg ies are needed to improve this essential aspect of history taking.