Successful applicants to the ASGE Endoscopy Unit Recognition Program submit a summary of a recently conducted quality improvement (QI) project as part of the application process. The QI project in the spotlight this month addresses accurate documentation of allergies.
STATEMENT OF PURPOSE
To correctly and accurately document patient’s allergies in the patient’s medical record.
Effect on patient care/desired outcome
Documentation to include not just allergies that are severe or life-threatening but also sensitivities, intolerances, idiosyncratic reaction, and side effects. This documentation will ensure a safe outcome for the patient.
PERFORMANCE GOAL
To help improve overall patient safety and prevent medication errors.
DATA TO BE COLLECTED AND COLLECTION PROCESS
The data collected compared documentation of allergies of 30 patients during 1st quarter (January through March) to 20 patients during 4th quarter (October through December). Patients were selected randomly and assigned a number for reference and to ensure patient confidentiality. The chart was then reviewed to assess documentation of allergies, the allergic reaction to the allergen and the severity of the medication. Also, that the allergies were reviewed and updated each time the patient had an appointment, whether in office or for a procedure.
COLLECTED DATA
The collected data was reviewed and documented on a standardized form provided by AAAHC the Chart Specific form.
ANALYZE FINDINGS
In accordance with the criteria listed above the findings were as follows:
- During the 1st quarter the patient’s allergies were correctly documented 47% of the time.
- Following staff education on what qualifies as correctly documenting patient’s allergies, during 3rd quarter correct documentation improved to 90%.
COMPARE FINDINGS TO GOALS
Using this quality improvement study, correctly documented patient’s allergies improved by 43%.
IMPLEMENTATION OF CORRECTIVE ACTIONS
An allergy documentation check was added to the monthly Quality Assurance (QA) forms. [EHR vendor] also added patient allergies documented during admission to paper discharge instructions patient receives prior to leaving facility.
REMEASUREMENT OF DATA
Correct documentation of patient’s allergies will continue to be monitored each quarter by the QA chart checks.
COMMUNICATION OF FINDINGS WITH GOVERNING BODY
These findings were discussed at the QA meeting where it was agreed upon to add the patient’s allergies to the discharge instructions per AAAHC recommendations. Also discussed education of office staff when initially documenting patient’s allergies during initial office visit and updating these allergies each office visit.
We hope sharing this project summary will be useful to you and your practice. Learn more about gaining honoree status in the ASGE Endoscopy Unit Recognition Program. The journey begins with the ASGE Improving Quality and Safety in Your Endoscopy Unit course. The next course takes place Saturday, October 2. Register today! Questions should be directed to eurp@asge.org.