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Policy for the safer use of medicines in people with allergies Background Serious harm has occurred when patients have been prescribed medication to which they have a pre-existing allergy. Prevention of such incidents relies on patient and medication information being available and acted on at the time of prescribing, dispensing and administration. This type of error can be easily prevented. The recent Department of Health report “Building a safer NHS for patients; Improving Medication Safety”, recommends that the Trust implements a written standard for the documentation of drug allergies, including roles and responsibilities of different health care professionals involved in the medication process. The issue is also a high priority for the National Patient Safety Agency. The relevant sections of the Medicines Code cover some of the issues. Although this policy deals with medication some food allergies may be relevant, such as lactose as an additive and nut oils as carriers of injections and topical products. Medicines Code Prescribing 4.5.8 Allergies and Sensitivities: The prescriber is responsible for entering any known allergy or sensitivity in the appropriate section of the prescription sheet and transferring these to subsequent sheets. Where there are no known allergies or medicine sensitivities, "No reported allergies" must be entered into this prescription sheet box and signed. Leaving this section blank could lead to an interpretation that the allergy status has not been considered when prescribing medication. This is essential data and if not completed may result in delay in obtaining treatment for the patient. It is also important for a warning label concerning known medicine sensitivity to be attached to the outside cover of both the patient's medical and nursing notes, to highlight this information to other prescribers in the future. Nurses and other practitioners should assist in identifying medicine sensitivities. Medicines should not be prescribed, administered, or dispensed when the allergy status is not known, unless in an emergency. Dispensing Pharmacy staff will refer back to the prescriber if the required information is not documented. Administration Nursing staff will refer back to the prescriber if the required information is not documented. Clinical Information Anaphylaxis Anaphylaxis is a serious allergic drug reaction that may be fatal. Medications frequently associated with anaphylactic reactions Aspirin and other non-steroidal anti-inflammatory drugs Heparin Amoxicillin (an antibiotic, a penicillin) Vaccines Suxamethonium (a muscle relaxant used in anaesthetics) Allergen extract (used for allergy testing) Trimethoprim (an antibiotic) Atracurium (a muscle relaxant) Ciprofloxacin (an antibiotic) Intravenous iron Intravenous vitamins (Pabrinex) and to a lesser extent intramuscular vitamins Lidocaine (a local anaesthetic) Propofol (an intravenous sedative) Thiopental (an intravenous sedative) Blood products Colourants, preservatives and excipients, such as lactose, used as additives Particular care should be taken with those people who report a penicillin allergy, as the nomenclature of many products does not immediately suggest that it contains a penicillin. Some penicillins and penicillin-containing antibiotics Benzylpenicillin (penicillin G) Procaine benzylpenicillin (procaine penicillin) Phenoxymethylpenicillin (penicillin V) Flucloxacillin Ampicillin Amoxicillin (amoxycillin) Co-amoxiclav (amoxicillin with clavulanic acid) = Augmentin Co-fluampicil (flucloxacillin with amoxicillin) = Magnapen Piperacillin Penicillin sensitive patients may also be allergic to cephalosporins and other beta-lactam antibiotics, which are structurally related to the penicillins Cephalosporins; Cefaclor, cefadroxil, cephalexin, cephamandole, cefazolin, cefixime, cefotaxime, cefoxitin, cefpirome, cefpodoxime, cefprozil, ceftazidime, cefriaxone, cefuroxime Other beta-lactam antibiotics; azteonam, imipenem with cilastin, meropenem Reducing the risks Recommendations from the Improving Medication Safety report Implement a written standard Audit allergy documentation against this standard. Allergy status of every patient should be written in a prominent position in the medical notes and be referred to each time the patient is reviewed. This should even be done when the patient has no known allergies. All paperwork used for prescribing medicines should include a section for documenting allergy status Allergy status should be documented on all hospital charts used for prescribing medicines so that it is visible at the point of prescribing, dispensing and drug administration. All staff should be made aware of their responsibilities with regard to allergy status documentation. Consideration should be given to a universal symbol that denote penicillin allergy, which could be used on packaging, notes, inpatient identity bands and medical alert bracelets. This would make the allergy status readily distinguishable. If an allergy develops during the hospital stay the medical records must be updated to reflect the current allergy status. SWYMHT recommendations As above Reasonable steps should be taken to check the allergy status of all patients prior to the prescribing of any medication. This includes inpatients, out patients, those on long term repeat prescriptions and those receiving drug treatment via a community-based team. The steps taken to check allergy status should include as a minimum: o Asking the service user or carer. Other useful sources of information which should be considered o Checking the relevant section of case notes (for some years in many Trusts this has been the front or inside front cover of the notes) o Checking the allergy section of previous prescription and administration charts. o Contacting the GP If no record of a proven allergy is found then the prescriber should write “No allergies reported” and date the entry in the allergy section of the prescription. The steps taken should be clearly recorded in the notes. If a report of an allergy is evident the name of the drug or group of drugs and any known reaction should be entered on the prescription and the entry dated. Each time a new prescription is written the allergy status should be transcribed onto the new prescription, including discharge prescriptions. Audit of completion of prescribing documentation on an annual basis as required by the Clinical Negligence Standards for Trusts Encourage GPs to include allergy status information in referrals to secondary care. Limitations of the Policy It is acknowledged that users of mental health services often have many volumes of notes, dating back many years, which are often incomplete. Recording of allergy status routinely and in a consistent manner has only recently become the norm. Mental health and medical notes are kept separately and the latter are not always available at mental health consultations or admissions. We cannot guarantee completeness of primary care allergy status records. Approved by the Drug and Therapeutics Policy Action Group February 2005 For Review February 2007.