Assessment of Medication Errors That Involved Drug Allergies at a University Hospital

T. Aaron Jones, Pharm.D., Jackson A. Como, Pharm.D.


Pharmacotherapy. 2003;23(7) 

In This Article


Adult patients admitted to the University of Alabama Hospital, Birmingham, who were at least 19 years of age and had documentation in the PIN computer system of an allergy to -lactam antibiotics, sulfonamides (including diuretic agents), and/or opioid narcotics were randomly selected for an interview. Patients able to communicate verbally or in writing and to give written informed consent were interviewed to determine the timing, nature, and extent of the reaction ( Table 1 ). From November 24, 2000-February 26, 2001, data were collected on 50 patients who were located on 1 of 10 preselected nursing units.

Studies indicate a wide variety of reported drug allergies, with the predominant groups of drugs falling into three classes: -lactam antibiotics, sulfur-containing drugs, and opioid narcotics.[1,3] Therefore, our research project focused on patients who reported an allergy to any agent in these three drug classes as documented in the PIN system. Using the information obtained by the patient interview and chart documentation, we assessed the reported allergy. Any allergy that was determined to be other than a true drug allergy was discussed with the appropriate medical staff by either direct or indirect communication (i.e., written note in patient's chart).

To achieve the second primary objective, all medication error reports received by the Drug Information Service were reviewed to identify errors that involved drug allergies. Prescribers were contacted to ascertain possible contributing factors. This assessment allowed for the determination of the most common reasons for this type of error.

Only descriptive statistical analyses were performed on the data obtained. To assess the documentation of drug allergies in our patient population, the information obtained during patient interviews was analyzed by the pharmacist and assigned to one of five categories ( Table 2 ).[1] This classification enabled the occurrence of true drug allergies for the previously mentioned drug classes to be identified in a specific patient population. The ramifications of the labeled drug allergy were also assessed by evaluating the administration of drugs with respect to the reported drug allergy. To assess the contributing factors involving medication errors, the information obtained from contacting prescribers was analyzed by the pharmacist and assigned to one of six categories: not aware of allergy; aware of allergy, but benefit greater than risk; not aware agent in same class; allergy not actual; agent within automatic order set; other. In addition, prescribers were questioned as to any specific information regarding the patient's reported drug allergy.