Adverse Drug Reaction (ADR) Reporting Guidelines

Note: See Fluid and Medication Manual (Volume 12) - Adverse Reactions Identification And Documentation.

Nursing Staff

1. If you suspect an ADR:
   • Notify medical staff.
   • Record the suspected ADR details in patient's clinical notes.
2. Ensure the medical team review any potential ADRs and that they update this on the medication chart(s).

Medical Staff

• If an ADR is suspected, assess the potential ADR, including the ADR probability scale.
• Document your assessment in the clinical notes.

1. If an ADR is possible (i.e. ADR Probability Scale ≥ 1) and relevant to future treatment decisions, you must:
   • Document the ADR in MedChart and record the details in the clinical notes.
   • If the patient has any active paper medication charts, complete an Adverse Reaction section by including the medicine, diagnosis, or description of the reaction, and approximate date of reaction.
     • For the National Medication Charts, write this in the ADR section.
     • For other charts (e.g. oxygen and infusion charts) add ADR sticker and complete.
   • For COVID-19 vaccine ADRs, also complete the specific CARM COVID reporting form (if you have difficulty opening this form, copy the URL (https://report.vaccine.covid19.govt.nz/s/) and open in Microsoft Edge or Google Chrome).
   • For all other ADRs, complete the ADR form on the intranet (Clinical Pharmacology Home Site).
   • Consider a MedicAlert (www.medicalert.co.nz, 0800 840 111), discuss this with the patient, and complete the form for the patient.
   • Communicate the ADR to the GP.
     • On discharge, MedChart alerts are loaded automatically to discharge summaries.
     • If not using MedChart, add the drug, type of reaction, and approximate date of reaction to the clinic letter or encounter summary.
2. If an ADR is doubtful (i.e. ADR Probability Scale < 1):
   • Remove the ADR alert from MedChart and cross out the writing or Adverse Reaction sticker on any paper medication charts.
   • Document this action in the clinical notes.
   • Document this in the discharge summary to notify the GP.
   • If the ADR is on the national medical warnings system, notify CARM to get it removed. Do this by completing an ADR form with the evidence that supports that this adverse reaction was not drug related.
3. In addition to the above, for:
   • ADRs involving anaesthetics, refer to the Anaesthetics Department for review.
   • Suspected anaphylactic reactions, refer to immunology.

Clinical Pharmacists

1. Notify medical and nursing staff that an ADR is suspected.
2. Record ADR details in the patient’s clinical notes.
3. Document the ADR in MedChart and block further administration of the medicine.
   • Complete an Adverse Reaction section on any active paper medication charts.
4. Prompt the medical staff to assess the suspected ADR.
5. Ensure the ADR is reported, via the ADR form on the intranet (Clinical Pharmacology Home Site).

Previous ADRs

An accurate up-to-date record of ADRs is required for all patients. An ADR is a diagnosis that affects treatment decisions now and in the future.

Medical and Pharmacy Staff

• These are potential sources of information for records of ADRs:
  • the patient and/or carer
  • any Medic Alert bracelets/pendants/wallet cards
  • all referral and transfer documents
  • the patient's clinical records (CDHB and other accessible records)
  • the National Medical Warnings System (Health Connect South, patient summary page)
• If there is any uncertainty, assess the validity of the ADR.
• Record the ADR details in the patient’s clinical notes.
• Add or update the ADRs in MedChart – include the drug (D), clinical diagnosis (R), and date of the reaction, and complete an ADR sticker to add to any active paper medication charts.
• If the previous ADR is not documented in the national alerts database for the patient, consider reporting this to CARM by completing the ADR form on the intranet.

Nursing Staff

• Check for ADRs in the patient’s medication chart, with the patient themselves and check any Medic Alert bracelets.
• If you identify an ADR that is not documented in MedChart:
  1. Record the potential ADR in the clinical notes.
  2. Notify the medical staff and request they assess the ADR.
  3. Withhold the affected medicine pending assessment. If the affected medicine is possibly "urgent", contact medical staff urgently.

Topic Code: 93318

must be prescribed or recommended by a consultant.