Medicines reconciliation: auditing the accuracy of penicillin allergy documentation in patient health records

Objectives This study aimed to assess the accuracy of penicillin allergy (PenA) documentation in patient health records (PHRs) and evaluate its implications for medicines reconciliation and antimicrobial prescribing practices. Methods A prospective audit was conducted in a Northern Ireland hospital between May and September 2023. Data were collected from PHRs of adult inpatients across medical and surgical wards, focusing on PenA documentation and adherence to antimicrobial prescribing guidelines. Statistical analysis included chi-square tests and descriptive statistics. Key findings Among 79 PHRs assessed, PenA documentation was significantly more prevalent in PHRs which underwent medicines reconciliation compared with those that did not (P = .004). However, a substantial portion of reconciled PHRs still lacked PenA documentation. Errors were identified, including incorrect labelling and discrepancies between PHRs and clinical observations. The study did not find a direct impact of PenA documentation on antimicrobial consumption patterns, though adherence to antimicrobial prescribing guidelines varied. Surgical wards demonstrated better compliance with guidelines compared with medical wards. Conclusions This study highlights deficiencies in PenA documentation during medicines reconciliation, emphasizing the need for improved documentation practices to enhance patient safety. Strengthening antimicrobial stewardship efforts through education, enhanced documentation protocols, and digitalized reconciliation processes could mitigate risks associated with inaccurate allergy labelling. Future research should explore strategies to optimize documentation accuracy and their impact on antimicrobial prescribing.