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What I learnt from my adverse reaction near miss

Form-filling can be a tedious chore, but Dr Sabby Kant describes how a failure to transfer an adverse reaction from Lloyd George notes to the computer record almost proved fatal

Form-filling can be a tedious chore, but Dr Sabby Kant describes how a failure to transfer an adverse reaction from Lloyd George notes to the computer record almost proved fatal

The case

When faced with the regular pile of tedious letters and forms, it is tempting to take shortcuts. But not being fastidious when form-filling – however busy you are – can be full of pitfalls.

The simple form request was from the hospital via the patient who had dropped the form off at reception. It requested basic pre-operative data such as an up-to-date list of the current medication, summary of active problems and a record of any allergies or adverse reactions. Working in a practice proud of its comprehensive IT system, form-filling was a doddle as it usually did not require pulling out the patient's Lloyd George notes.

But a few weeks later I received a call from a stressed hospital anaesthetist calling from the operating theatre. She urgently wanted to confirm the patient's medication history as the patient was refusing to be anaesthetised. The patient was insisting that he had a history of a severe adverse reaction.

Six years ago, during pre-operative stages, he had suffered a serious reaction to an anaesthetic drug. He had required emergency treatment and spent a few days in intensive care.

This time the patient had attended for his pre-op check and had mentioned his previous history. But the pre-op check proforma simply said ‘allergy to anaesthetic' but no specific drug was mentioned as the patient could not recall its ‘complicated name'.

Somehow the patient had arrived at theatre without anyone questioning the query regarding the possible problem – hence the phone call from the stressed anaesthetist.

The outcome

I rechecked the patient's electronic records, which again showed an empty space in the allergy field. An urgent request for the patient's Lloyd George records from the records room brought my staff clutching a set of notes – two Lloyd George envelopes fastened together.

Hidden on the top left corner of the Lloyd George envelope of the second set was a statement written in red saying ‘allergy to anaesthetic'. The traditional method has always been to write any significant adverse reactions on the actual Lloyd George envelope as well as in the red summary card.

After perusing the records, I eventually found a hospital letter describing the patient having a serious reaction pre-operatively. The culprit drug was suxamethonium and the information was passed onto the relieved anaesthetist. Subsequently the patient underwent a successful and uneventful operation with the use of an alternative anaesthetic agent.

Why it nearly went wrong

It is all too easy to over-rely on computerised records for the sake of convenience. In this case it was assumed that our system for transferring data from the patient's written records onto computerised records was robust. The recording of an adverse reaction on the written records was also flawed in that the specific drug was not recorded in the appropriate section on the summary card. Although recorded on the outside of the Lloyd George (the traditional method) – the exact drug was not written nor the type of severe reaction.

Furthermore, this note on the first set of Lloyd George notes had not been transferred to the second attached envelope, which was bound to the first – thus hiding the relevant record.

We went on to comprehensively audit-check the front of Lloyd George envelopes in 8,000 patients. We identified more than 200 allergies or adverse effects of which a whopping 60% had not been translated into the patients' electronic records.

Moral of the story

Don't assume allergy or adverse event recording is accurate on computerised records. The system of transferring records of new patients onto the computer has to be robust. As practices often inherit huge retrospective records, it is essential that training and quality standards monitoring systems are in place. Practices mustn't solely rely on computerised records as there will often be important retrospective information that has not been transferred onto the computer.

Dr Sabby Kant is a GP in Northwood, Middlesex

Lloyd George notes

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