Transcript Standard IM.3.10 - Washington Patient Safety Coalition

Unsafe Abbreviations:
MultiCare Health System
Celeste Derheimer, RN, MBA, CPHQ
Washington Patient Safety Coalition
January 19, 2006 Teleconference
MultiCare Health System
Acute
Care & Surgical
Centers
– Allenmore Hospital
– Mary Bridge Children’s
Hospital & Health Center
– Tacoma General Hospital
– MultiCare Day Surgery
Centers
MultiCare Clinics
• Auburn
• Lakewood
• Covington • Northshore
• East Hill
• Spanaway
• Gig Harbor • University Place
• Kent
• Westgate





Laboratories Northwest
MultiCare HealthWorks
MultiCare Home
Services
MultiCare Medical
Associates
MultiCare Urgent Care
Centers
• Covington • Lakewood
• Gig Harbor
• University
Place
• Kent
• Westgate
JCAHO Surveys

Three surveys in two weeks in
April
– Tacoma General/Allenmore
– Mary Bridge Home Infusion
– Mary Bridge Children's Hospital

Then we had two more in August
– Home Health
– Hospice
JCAHO Survey Experience
Mary Bridge Children’s Hospital and
Mary Bridge Home Infusion
Services (April ’05)
 Home Health and Hospice (August
’05)

– No unsafe abbreviations observed!!
Use of Unsafe Abbreviations
Results – Mary Bridge Children’s
25%
20%
20%
15%
10%
6%
8%
2%
5%
2%
1%
0%
0%
Q4-03
Q1-04
Q2-04
Q3-04
Q4-04
Q1-05
Q2-05
JCAHO Survey Experience

Tacoma General/Allenmore Hospitals
(April ’05)
– Although the hospital had a list of
abbreviations, acronyms and symbols not
to use, this list was not consistently
followed throughout the institution.
– Four uses of unacceptable abbreviations
(qd, u and MSO4) by four different
practitioners (2 physicians, a nurse and a
pharmacist) were found on 3 different
patient tracers.
Use of Unsafe Abbreviations
Results – Tacoma General/Allenmore
60.0%
57.0%
55.4%
50.0%
40.4%
40.0%
30.0%
27.5%
20.0%
17.0%
23.5%
10.0%
13.4%
0.0%
Q4-03
Q1-04
Q2-04
Q3-04
Q4-04
Q1-05
Q2-05
Unsafe Abbreviation Use by Profession
100%
RPh
90%
RN
80%
MD
70%
60%
50%
40%
30%
20%
10%
0%
Q4-03
Q1-04
Q2-04
Q3-04
Q4-04
Q1-05
Q2-05
Addressing the RFI

Don't need to revise our policy or
develop a new/different list!!
– Provide additional
training/education in areas were we
know there is need
– Focus on unit-level data collection
and "immediate" results feedback
(positive as well as improvement
opportunities)
Tools and Steps
Unsafe Abbreviation (USA) Task
Force met every other week
 A unit-specific data collection tool
was developed.

– Each task force member piloted the
data collection tool over a two-week
period.
– The tool was used to collect data
concurrently and provide 1:1, just-intime education.
Tools and Steps



Using Rapid Cycle Improvement
concepts, the tool was reviewed and
revised until the tool/process were ready
for implementation.
Once the tool was ready for
implementation, unit staff conducted
random audits of three charts/week/unit
Data was submitted to Quality,
aggregated and returned to the units
where they were displayed and
discussed in staff meetings
Tools and Steps
Posters were placed in areas
where Medical Staff would see
them (Physician Lounges, OR,
Medical Records)
 Letter from the Medical Officer and
article in MedStaff News
 Updates at all Medical Staff
Meetings and CME offerings

Tools and Steps

As the data started coming in,
Quality Management developed
Physician Specific Reports.
– Display of the percent use of unsafe
abbreviations by abbreviation
– A second graph provided a blinded
summary of Percent use of Unsafe
Abbreviations by Practitioner
Tools and Steps



Posters were placed in areas where Medical
Staff would see them (Physician Lounges,
OR, Medical Records)
Update article in MedStaff News with the
same information
Emails with the same information and graphs
were sent to individual physicians providing
them with their “code”
The Results
Percent Use Unsafe Abbreviations
14.0%
12.5%
12.0%
10.0%
9.5%
7.8%
8.0%
6.0%
3.8%
4.0%
3.0%
2.0%
0.0%
August
September
October
November
December