the use of abbreviations and dosage

N O T E Educational interventions to reduce use of unsafe abbreviations MOHAMMED E. ABUSHAIQA, FRANK K. ZARAN, DAVID S. BACH, RICHARD T. SMOLAREK, AND MARGO S. FARBER The use of abbreviations and dosage designations in medication prescribing has received much attention recently and has become a national concern as one of the major causes of medication errors. 1-3 The use of abbreviations is a longstanding practice among health care practitioners, and these shortcuts often appear in order forms, standing protocols, and policies. 4 However, some abbreviations may be misinterpreted, leading to medication errors. The risk of misinterpreting an abbreviation is even greater with handwritten orders, as the handwriting may be illegible. 4 The idea of eliminating the use of abbreviations is not new. For example, the Institute for Safe Medication Practices has expressed this sentiment for 25 years, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has mandated that specific abbreviations not be used in clinical communications. 4-7 Many other organizations, including the Institute of Medicine, Purpose. Educational interventions to reduce the use of abbreviations and dosage designations that were deemed unsafe at a level 1 trauma center are described. Summary. Strategies to reduce the use of unsafe abbreviations at Detroit Receiving Hospital were studied. Six abbreviations and dosage designations were deemed as unsafe by the site s medication-use and patient medical safety committees: (1) U for units, (2) µg for microgram, (3) TIW for three times a week, (4) the degree symbol for hour, (5) trailing zeros after a decimal point, and (6) the lack of leading zeros before a decimal point. Data on abbreviation use was collected starting in September 2003 by examining copies of patients order sheets, which are sent from nursing units to the pharmacy for processing. Data were collected during three 24-hour periods each month, with 7 10 days between each period. A data collection sheet was developed to assist in documenting the number of opportunities for each unsafe abbreviation and the actual incidence of each. American Society of Health-System Pharmacists (ASHP), Food and Drug Educational strategies were developed and implemented starting in October 2003 to decrease the use of the unsafe abbreviations. These strategies included inservice education programs for the medical, pharmacy, and nursing staffs; laminated pocket cards; patient chart dividers; stickers; and interventions by pharmacists and nurses during medication prescribing. During the eight-month evaluation period, 20,160 orders were reviewed, representing 27,663 opportunities to use a designated unsafe abbreviation. Educational interventions successfully reduced the overall incidence of unsafe abbreviations from 19.69% to 3.31%. Conclusion. Educational interventions markedly reduced the use of unsafe abbreviations in medication orders over an eight-month evaluation period. Index terms: Abbreviations; Dosage; Education; Errors, medication; Health professions; Hospitals Am J Health-Syst Pharm. 2007; 64:1170-3 Administration (FDA), National Coordinating Council for Medication MOHAMMED E. ABUSHAIQA, PHARM.D., is Assistant Director, Medication Department, Medical Supply, General Administration of Medical Services Ministry of Interior, Riyadh, Saudi Arabia; when this study was conducted he was Pharmacy Practice Management Resident, Detroit Receiving Hospital (DRH)/University Health Center (UHC), Detroit, MI. FRANK K. ZARAN, B.S.PHARM., is Clinical Pharmacist Specialist, Drug Information Services, Department of Pharmacy Services, DRH/UHC. DAVID S. BACH, PHARM.D., M.P.H., FASHP, is Executive Director, Pharmacy Services, Detroit Medical Center (DMC), and Director, Pharmacy Services, DRH/UHC. RICHARD T. SMOLAREK, M.S., is Director of Pharmacy, Department of Pharmacy Services, Children s Hospital of Michigan, Detroit. MARGO S. FARBER, PHARM. D., is Manager, Drug Information/Drug Use Policy, DMC. Address correspondence to Dr. Abushaiqa at the Medication Department, Medical Supply, General Administration of Medical Services Ministry of Interior, Riyadh 11492, Saudi Arabia (alsharif3@yahoo.com). Copyright 2007, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/07/0601-1170$06.00. DOI 10.2146/ajhp060173 1170 Am J Health-Syst Pharm Vol 64 Jun 1, 2007

Error Reporting and Prevention, and American Hospital Association, warn that the use of inappropriate abbreviations may lead to confusion and communication failures. 4-7 In July 2003, JCAHO created a new standard requiring institutions to identify six unsafe abbreviations which may not be used in clinical communication or documentation, including medication orders. In November 2003, JCAHO revised this standard to include a specific list of abbreviations that it deemed unsafe and required institutions to identify an additional three abbreviations that could not be used by April 2004. 7 This article describes one institution s efforts to reduce the use of abbreviations and dosage designations that were deemed unsafe. Background. Detroit Receiving Hospital (DRH) is a 340-bed, level 1 trauma center located in downtown Detroit, Michigan. DRH is part of the Detroit Medical Center and serves as a training center for schools of medicine, nursing, and pharmacy. Approximately 50% of the physicians who practice in southeast Michigan have been trained at DRH. In response to JCAHO s initial mandate regarding unsafe abbreviations, DRH s medication-use and patient medical safety committees identified six unsafe abbreviations and dosage designations that were no longer to be used: (1) U for units, (2) µg for microgram, (3) TIW for three times a week, (4) the degree symbol for hour, (5) trailing zeros after a decimal point, and (6) the lack of leading zeros before a decimal point. (For simplicity, trailing and leading zeros, when used inappropriately, are called unsafe abbreviations in this article.) Data collection on abbreviation use began in September 2003 by examining copies of patients order sheets, which are sent from nursing units to the pharmacy for processing. Data were collected during three 24-hour periods each month, with 7 10 days between each period. A data collection sheet was developed to assist in documenting the number of opportunities for each unsafe abbreviation and the actual incidence of each. Opportunities were defined as the use of a designated unsafe abbreviation or its safer alternative, and incidence was defined as the number of times an unsafe abbreviation was used divided by the number of opportunities for its use. Since pharmacists contacted prescribers when disallowed abbreviations were detected, the resulting rewritten orders were not counted as opportunities. Interventions. After data collection in September 2003, educational strategies were developed and implemented starting in October 2003 to decrease the use of the unsafe abbreviations. These strategies included inservice education programs for our medical, nursing, and pharmacy staff and contacting prescribers to clarify orders containing these abbreviations and explaining why they may not be used. In addition, memorandums and e-mails from DRH s medical officers were sent to all health care staff. Additional educational materials included pocket cards, medical chart dividers, and stickers. The laminated pocket cards were two-sided. One side included notes about safe prescription-writing practices and policies, and the other side provided a list of the designated unsafe abbreviations and their intended meanings, misinterpretations, and recommended safe alternatives. The medical chart dividers contained the same information as the laminated pocket cards and were placed in all patients medical charts. These dividers separated medication and laboratory orders from the rest of the chart. Stickers designed to look similar to traffic signs were used to identify prohibited activities. Each sticker bore a specific prohibited abbreviation surrounded by a large red circle with a slash through it. These stickers could be worn on clothing (e.g., laboratory coats, shirts) and were distributed to staff to remind them to avoid the use of these abbreviations. The results of these interventions were regularly reported to DRH s medication-use (the site s pharmacy and therapeutics committee) and patient medical safety committees. Additional memorandums and e-mails were sent to staff when deemed necessary, based on the incidence of use of the identified abbreviations. Experience. During the eightmonth evaluation period, 20,160 orders were reviewed, representing 27,663 opportunities to use a designated unsafe abbreviation. Baseline data were collected in September 2003, and the incidence of unsafe abbreviations was found to be 19.69% (Table 1). Initial staff education began the following month. In November 2003, the incidence of unsafe abbreviations declined to 16.56%, when pharmacists began contacting prescribers to clarify the intent of unsafe abbreviations. Use of unsafe abbreviations continued to decline over the following months, and at the end of our study period the overall incidence of unsafe abbreviations was 3.31%. The use of specific unsafe abbreviations declined from baseline, with 100% compliance with JCAHO standards (0% incidence) noted for three of them (Table 2). Investigation into why some prescribers failed to include a leading zero before a decimal point revealed that this omission occurred most frequently in orders for i.v. 0.9% sodium chloride injection. Subsequent e-mails and memorandums sent in February 2004 alerted medical, pharmacy, and nursing staff to this problem. By April 2004, the lack of a leading zero had declined from 17.9%, which exceeded the baseline 12.8% incidence, to 3.2%. Discussion. In November 2003, JCAHO revised its standards to include a specific list of abbreviations Am J Health-Syst Pharm Vol 64 Jun 1, 2007 1171

Table 1. Opportunities for and Occurrences of Unsafe Abbreviation Use Month and Year a Total No. Orders No. Opportunities that it deemed unsafe. As a result, it required us to add additional abbreviations to our do not use abbreviation list: qd, qod, MS, MSO 4, and MgSO 4. In addition, it required institutions to identify an additional three abbreviations that could not be used by April 2004. We started incorporating JCAHO s revised list of unsafe abbreviations, which includes many of the abbreviations we initially identified, in our educational process; but for the purpose of our evaluation, we limited our assessment to reduction in the use of the unsafe abbreviations initially identified by DRH. The increasing number of prohibited abbreviations can make it difficult for staff to remember them all. Therefore, it was important to keep the staff up to date on any changes in the program. Educational materials No. Occurrences Frequency (%) b Sep 2003 2,990 4,149 817 19.69 Oct 2003 2,170 2,890 581 20.10 Nov 2003 2,426 3,073 509 16.56 Dec 2003 2,261 3,268 263 8.05 Jan 2004 2,560 3,175 213 6.71 Feb 2004 3,015 3,912 294 7.52 Mar 2004 2,465 3,751 140 3.73 Apr 2004 2,273 3,445 114 3.31 Total 20,160 27,663 2,931 10.60 a Baseline data were collected in September 2003, and educational interventions started in October 2003. b Incidence = (no. occurrences/no. opportunities) x 100. Table 2. Use of Unsafe Abbreviations Before and After Program Implementation Unsafe Abbreviation Frequency (%) Sep 2003 Apr 2004 TIW 0 0 µg 29.0 0 Trailing zero 0.7 0 U 22.0 7.3 Degree symbol 61.0 9.3 Lack of leading zero 13.0 3.2 were revised to reflect the new list of unsafe abbreviations. A screen saver containing the unsafe abbreviations, their intended meanings, common misinterpretations, and recommended alternatives was added to all inhouse computers. In addition, inservice educational programs are planned to be presented to new residents, staff, and students in medicine, pharmacy, and nursing schools. Part of the education process involved notifying prescribers when they used an unsafe abbreviation/ dosage designation. When pharmacists encountered an order containing an unsafe abbreviation or dosage designation, they contacted the prescriber to clarify the order and, when necessary, obtained an oral order, which would be rewritten using a safer alternative. Beginning in July 2004, orders containing a designated unsafe abbreviation or designation were no longer accepted, and the prescriber was required to rewrite the order. In other words, prescribers could no longer issue oral clarifications of orders containing these terms. Instead, the prescribers or the prescribers following their service (e.g., oncall physicians) had to rewrite the orders themselves. According to a 2005 ASHP national survey of pharmacy practice in hospitals, 52% of hospitals have achieved the JCAHO goal of eliminating the use of unsafe abbreviations and dosage designations. 8 Factors that enhanced DRH s successful elimination of unsafe abbreviations included medical staff support and pharmacy staff follow-up. Other institutions have also developed novel ways of bringing this issue of unsafe terminology to their staff and teaching them safer alternatives. One institution provided its staff with T-shirts with a list of the good abbreviations on one side and a list of the bad abbreviations on the other. 9 While this strategy did not eliminate the problem, it did result in some improvement. The process of contacting prescribers when encountering unsafe abbreviations and dosage designations can increase pharmacists workload and create the perception that they are the abbreviation police. It is important to remind pharmacy staff that avoidance of these terms is important for improving patient safety and that this standard is not unique to one institution but is being implemented across the country. The avoidance of these abbreviations is the responsibility of all health care practitioners, and pharmacy is responsible only for following up on their use on medication orders. Other departments will follow up on the use of these abbreviations in other documentation. Moreover, tracking the use of unsafe abbreviations is a part of the performance improvement process mandated by JCAHO. 1172 Am J Health-Syst Pharm Vol 64 Jun 1, 2007

There is no specific time limit in our institution to stop these efforts to reduce the use of unsafe abbreviations and dosage designations. Pharmacists must view the task of contacting prescribers when they encounter unsafe abbreviations as part of their everyday practice and no different from obtaining clarification of any other questionable order. By treating it as such and routinely calling for clarifications, the use of these abbreviations should decline over time. Consequently, the number of follow-up calls required should decrease. Resistance from the medical staff, while a reasonable concern, was not encountered in our institution. On the contrary, our medical staff leadership and hospital administration have been very supportive of our efforts. Conclusion. Educational interventions markedly reduced the use of unsafe abbreviations in medication orders over an eight-month evaluation period. References 1. Lassetter JH, Warnick ML. Medical errors, drug-related problems, and medication errors: a literature review on quality of care and cost issues. J Nurs Care Qual. 2003; 18:175-81. 2. Barker KN, Flynn EA, Pepper GA et al. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002; 162:1897-903. 3. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997; 277:312-7. 4. Institute for Safe Medication Practices. Hospital and medical staff leadership is key to compliance with JCAHO dangerous abbreviation list. www.ismp.org/ Newsletters/acutecare/articles/20040812_ 2.asp (accessed 2007 Feb 15). 5. American Society of Health-System Pharmacists. Guidelines on preventing medication errors in hospitals. www.ashp.org/ s_ashp/docs/files/medmis_gdl_hosp.pdf (accessed 2007 Feb 15). 6. National Coordinating Council for Medication Error Reporting and Prevention. Council recommendations. www. nccmerp.org/councilrecs.html (accessed 2007 Feb 15). 7. Joint Commission on Accreditation of Healthcare Organizations. The official do not use list. www.jointcommission.org/ PatientSafety/DoNotUseList/ (accessed 2007 Feb 15). 8. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration 2005. Am J Health- Syst Pharm. 2006; 63:327-45. 9. Traynor K. Enforcement outdoes education at eliminating unsafe abbreviations. Am J Health-Syst Pharm. 2004; 61:1314,1317,1322. Am J Health-Syst Pharm Vol 64 Jun 1, 2007 1173