Transcript Standard IM.3.10 - Washington Patient Safety Coalition

Unsafe Abbreviations:
MultiCare Health System
Will Barnes, Celeste Derheimer and
Margo Forstrom
Washington Patient Safety Coalition
May 25, 2005 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
National Patient Safety Goals


The Joint Commission’s Board of
Commissioners approved the first National
Patient Safety Goals in July 2002. JCAHO
established these goals to help accredited
organizations address specific areas of
concern in regards to patient safety.
Goals and recommendations are announced
in July and become effective on January 1 of
the following year.
Unsafe Abbreviations (USA)

As of January 1, 2004, all JCAHO accredited
health care organizations are being surveyed
for implementation of goal 2a: Improve the
effectiveness of communication among
caregivers.
– This goal states specifically: Standardize the
abbreviations, acronyms and symbols used
throughout the organization, including a list of
abbreviations, acronyms and symbols not to use.
[Scored at Standard IM.3.10, EP #2].
Standard IM.3.10

Compliant Not/Compliant
– The hospital has processes in place to
effectively manage information,
including the capturing, reporting,
processing, storing, retrieving,
disseminating, and displaying of
clinical/service and non-clinical data
and information.
Element of Performance:
IM.3.10 - #2

Abbreviations, acronyms, and
symbols are standardized
throughout the hospital and there
is a list of abbreviations,
acronyms, and symbols not to
use.
Institute for Safe Medication
Practice (ISMP)

“Absent scientific research to prove its
effectiveness, the evidence for this error reduction
strategy is nonetheless obvious. Similar to
removing potassium chloride concentrate vials from
patient care areas and providing timely pharmacy
distribution of solutions, you don’t need scientific
validation to prove that such action will prevent the
drug from being given IV push. Similarly, we have
enough obvious evidence that using “U” for “units”
has led to countless tenfold overdoses of insulin,
heparin, and penicillin G (including an infant death
from hyperkalemia).”
The Challenge


Developing and implementing a plan
that would result in successfully
eliminating the use of Unsafe
Abbreviations throughout MultiCare
Health System (MHS).
One of the elements that added to the
complexity is the fact that the goal
relates to multiple disciplines; basically
– anyone who documents in the patient
record.
The Real Challenge

Change daily practice that was
previously acceptable and is an
ingrained habit for our medical,
nursing and pharmacy staff.
– These abbreviations are taught to
medical and allied health personnel
in school as part of our training and
are in use in everyday practice –
making the challenge considerable.
Team Members







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



J.D. Fitz, MD, Hospitalist Medical Director
Karen Nilsen, MD, Acting Medical Director Mary
Bridge Hospital
Daniel Ginsberg, MD, Allenmore Hospital Executive
Committee
Richard Stubbs, MD, Vice President Medical Affairs
Candace Smith, Allenmore Hospital
Sue Hale, Mary Bridge Hospital
Vicki Skorupski, Tacoma General Hospital
Peg Isenhower, Home Health
Margo Forstrom, Pharmacy
Kathy Smoots, Pharmacy
Diane Leaton, MMG
Celeste Derheimer, Quality Management
Process

The first step in the process was
development of the unsafe abbreviations
list.
– To promote consistency in the community
the list was developed in collaboration with
other area hospitals and health systems.
– It was felt that this regional list would
facilitate implementation since the area
physicians would get the same message
regardless of where they practiced
USE THIS 
DON’T USE THIS 
MISINTERPRETATION
unit
U or u (for unit)
Read as a zero (0) or a four (4), causing a
10 fold overdose or greater (4U seen as “40
or 4u seen as 44”)
International units
IU (for international unit)
Misread as IV (intravenous) instead of
international units
1 mg (Do not use
terminal zeros for
doses expressed in
whole numbers)
Zero after decimal point
(1.0)
Misread as 10 mg if the decimal point is not
seen
0.5 mg (Always use
zero before a decimal
when the dose is less
than a whole unit)
No zero before decimal
dose (.5 mg)
Misread as 5 mg
Write “daily” and
“every other day”
QD or QOD (Latin
abbreviation for once
daily & every other day)
Mistaken for each other. The period after
the Q can be mistaken for an “I” and the “O”
can be mistaken for and “I” (QID).
Write “morphine
sulfate” or
“magnesium sulfate”
MS, MSO4 or MgSO4
Confused for one another. Can mean
morphine sulfate or magnesium sulfate
mcg
ug
Mistaken for “mg” when handwritten
resulting in a thousand-fold overdose
Use the Metric
System
Apothecary Symbols
Dram, Minim, Grain
Misunderstood or misread (symbol for dram
misread for “3” and minim misread as “mL”)
Spell out all
chemotherapy names
Chemotherapy drug
name abbreviations
Misread and wrong agent administered.
Initial Focus

The initial JCAHO goal related to
any handwritten documentation
– The team identified that the area of
focus would be on abbreviations
used in patient orders – since
implementation of orders that are
not clear would most likely result
error more often than unclear
handwritten documentation in the
progress or other notes.
Implementation

Tools for implementation were
developed
– Discipline specific learning modules
– Job aides such as the unsafe
abbreviations “checker board”
– Electronic billboards
– Listing the unsafe abbreviations on
the back of the order sheets so they
would be readily visible to anyone
responsible for writing orders.
Communication


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A communication plan was developed
that identified the various forums, such
as face-to-face meetings, written and
electronic mechanisms, and audiences
(e.g. physician, nursing, management
and staff).
In addition key themes that kept the
message consistent regardless of the
mode and/or audience were developed.
A letter to all physicians that practice at
a MultiCare hospital was sent out in
December 2003
Communication

Articles in Medical Staff News, MultiNews
and other written forums
– As compliance results became available, data
was included in all communications


Updates at various forums such as Medical
Staff Meetings, Management Forum and
the Profession Nurse Practice Council
A second letter to all physicians in July and
individual practitioner letters with copies of
orders (patient de-identified) where they
had used unsafe abbreviations in
September
Communication

Pharmacist and Nursing Education
– Self learning modules
– Department level training

Included in various orientation packets
– New employee
– Medical Staff and Medical Students
– Nursing and other allied health students
Implementation

The final major implementation task was
initiation of order clarification: Hand
written orders that contained any of the
MHS designated “Do Not Use”
Abbreviations are considered incomplete
orders;
– The individual who wrote the order is
contacted to clarify the intended meaning of
the abbreviation prior to carrying out the
order.
– Confirm the intended meaning of the
abbreviation or symbol and document in the
medical record.
Implementation

The team determined that the call
verification process would begin
September 1, 2004.
– Decision primarily based on use of USA
reduction to a manageable level
– An update was presented at the second
combined Medical Staff meeting in July; with
input from that group, the decision was made
to postpone the call verification process until
October 1, 2004.
Measurement

Baseline data for this project was
obtained in December 2003.
– Approximately one hundred orders per
acute care facility (Allenmore, Mary Bridge
and Tacoma General) and for the Neonatal
Intensive Care Unit (NICU) were reviewed
for use of unsafe abbreviations.
– The indicator was defined as the number of
unsafe abbreviations used per order.
• An “order” is specifically defined as a written
entry into the chart, consisting of at least one
line, by one practitioner at one time.
Measurement
The data was collected by chart
abstraction at least quarterly.
 Results were provided by facility,
by provider (Physician, Nursing
and Pharmacy) and by specific
unsafe abbreviation.

Use of Unsafe Abbreviations
Results - MHS
45%
40%
41%
35%
30%
29%
25%
18%
20%
16%
15%
17%
10%
10%
8%
5%
0%
Q4-03
Q1-04
Q2-04
Q3-04
Q4-04
Q1-05
Q2-05
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
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
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
% of total by Un-Safe Abbreviation
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Q4-03
Daily
Trailing 0
Q1-04
Q2-04
Unit
Naked Decimal
Q3-04
Q4-04
Morphine
All others
Q1-05
Q2-05
Magnesium
JCAHO Survey

Three surveys in two weeks
– Tacoma General/Allenmore
– Mary Bridge Home Infusion
– Mary Bridge Children's Hospital

Different teams; different styles;
VERY different experience
– 2 physicians, 3 nurses, 1 ambulatory
surveyor and 1 engineer
National Summit on Medical
Abbreviations

As a result of recommendations in November 2004,
the Executive Committee of the Joint Commission
has approved the following changes addressing the
scope of the requirements for NPSG 2b for 2005:
– It now applies to ALL orders and ALL medication-related
documentation that are handwritten, utilize free text entry
or employ pre-printed forms.
– The minimum expected level of compliance for handwritten
documentation and free text entry is 90 percent.The
minimum expected level of compliance for preprinted
forms is 100 percent.
– Clarification of an order prior to implementation is
expected but does not eliminate that occurrence from
being counted. Similarly, after-the-fact correction of the
order by the clinician does not eliminate that occurrence
from being counted.
JCAHO Scoring Changes

Surveyors will count occurrences of Do Not
Use Abbreviations.
 One occurrence equals one or more "slips" per
clinician per record.
 Three occurrences equal a Requirement for
Improvement. (Revised 1/21/05)
 There is no "partial compliance" for NPSGs.
 This requirement will not be surveyed in electronic
documentation or computerized order entry in
2005. (New 12/20/04)
Institute for Safe Medication Practice

"Organizations are no longer considered
compliant if pharmacists or nurses call a
prescriber for clarification and document the
intended meaning.
– The goal is to remove responsibility for prescriber
compliance from nurses and pharmacists, who've
previously been placed in a position of
enforcement, and redirect it to the medical and
administrative staff.
– As ISMP and others have pointed out, an
unintended and serious consequence of having
pharmacists and nurses shoulder this responsibility
has been friction created by numerous phone calls
and interruptions to clarify orders and educate
prescribers."
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.
JCAHO Survey Experience

Mary Bridge Children’s Hospital and
Mary Bridge Home Infusion
Services (April ’05)
– No unsafe abbreviations observed!!
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)
Lessons Learned
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The people/areas impacted by the
goal/standard have to own the work
As Task Force members change
jobs/leave – need a clear replacement
process
Need to provide direct feedback to
change individual behavior – especially
to those that are resistent
Keys to Success



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Collaboration with the Medical Staff and
Leadership and involvement of multiple
disciplines.
Communicating information, including
results, in multiple ways, multiple times.
Clearly defining the indicator and data
collection process and obtaining
baseline data.
Development of tools and processes for
implementation that will be useful in
other topic areas.
Keys to Success


National Standard – not a MultiCare
“mandate”
Community Push
– Regional P&T committees agreed on list
– Providers hear the same message at all
area hospitals


Focus on Patient Safety, not compliance
with JCAHO standard
One of our Focus Objectives for the
system – emphasized importance to
organizational success
Next Steps

Beyond hand written orders
– Forms Committee inventory, search
and destroy
– Electronic Medical Record

Beyond acute care
– Home Health/Hospice
– MultiCare Medical Associates