BETHESDA, MD, 04 Dec 2003—
Hospitals and other organizations have until January 1 to stop health care workers from taking nine specific shortcuts in handwritten communication that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) says endanger patients' safety.
The nine abbreviations "must be included on each accredited organization's 'Do not use' list," JCAHO announced October 27 on its Web page devoted to frequently asked questions about the National Patient Safety Goals for 2004.
One week later, JCAHO updated the Web page to notify organizations that, by April 1, they must add at least three abbreviations, acronyms, or symbols of their own choosing to the list of shortcuts never to use in patient-specific documentation.
Additional Abbreviations, Acronyms, and Symbols
To Consider Never Using
||half-strength or at bedtime
||3 times weekly or three times weekly
||Sub-Q, subQ, or subcutaneously
||Sub-Q, subQ, or subcutaneously
aAdapted from "2004 National Patient Safety Goals—FAQs," Joint Commission on Accreditation of Healthcare Organizations.
Straight-out attack on a problem. Rick Croteau, JCAHO executive director for strategic initiatives, including patient safety, said the unusual actions were taken because a sizable percentage of organizations had not fulfilled a requirement for which 100% compliance was expected.
"The issue was the specific requirement [in the 2003 National Patient Safety Goals] for a do-not-use list," he said. "And when it was initially implemented at the beginning of this year, the compliance with that safety goal was the worst of the bunch. The data for the first three quarters of the year . . . was 76% compliance in hospitals."
One of the six safety goals for 2003 was "Improve the effectiveness of communication among caregivers."
As part of meeting this goal, which was also selected for 2004, an organization had to "standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use."
But JCAHO surveyors found instances in which organizations had not taken to heart the requirements of the patient safety goals, which had been developed under the advice of an external panel of experts, the Sentinel Event Alert Advisory Group. ASHP Executive Vice President Henri R. Manasse Jr. has been the chair of the group since its formation in April 2002.
"In order to achieve compliance [with the goal], some organizations were in a sense playing games with it by having a list of one or two items," Croteau said, adding that he "had to point out that, by definition, a list is more than one."
The list of nine. The executive committee of the JCAHO Board of Commissioners on October 23 approved the following items as constituting the "minimum" do-not-use list:
- U (abbreviation for unit),
- IU (international unit),
- Q.D. (daily),
- Q.O.D. (every other day),
- Trailing zero after a decimal point,
- Lack of leading zero before a decimal point,
- MS (morphine sulfate or magnesium sulfate),
- MSO4 (morphine sulfate or magnesium sulfate), and
- MgSO4 (magnesium sulfate or morphine sulfate).
"I think there's a lot of evidence out there [indicating that] these abbreviations are fraught with problems," said Sherry Umhoefer, vice president of quality and compliance at McKesson Medication Management.
Problems with those abbreviations have been discussed by pharmacists for at least two decades, she said.
The new requirement appeals to Umhoefer because "now we've got . . . an imperative, a standard that's recognized."
By identifying which shortcuts must not be used in communications about patients, JCAHO now makes it possible, she said, for pharmacy to say, "Look, this is a standard—this is a proven standard, it's based on experience—this is what we are going to do."
An additional three by April. Patricia C. Kienle, medication safety manager for the pharmacy management business of Cardinal Health, said the interesting part of the recent announcements is the requirement for organizations to add at least three items to the nine specified by JCAHO by April 1.
"One thing pharmacies could do is identify for their organization what are commonly used abbreviations, since they see all the orders," she said. "Probably the only other people in the organization that see all the orders are the medical records people. So perhaps pharmacy, working with medical records, can identify some of these problematic abbreviations at each organization and start taking steps now to put them on the do-not-use list."
Another good source of ideas for additions to the do-not-use list, Kienle said, is drug-name abbreviations that can be misinterpreted, such as 6-MP for mercaptopurine.
Kienle is a member of the JCAHO Professional and Technical Advisory Committee for hospital standards but said the group did not contribute to the patient safety goals and requirements.
To help organizations build their do-not-use list, JCAHO offered several abbreviations, acronyms, and symbols for consideration (see table). JCAHO also suggested as a source the list of dangerous medication-related abbreviations compiled by the Institute for Safe Medication Practices.
Said Croteau: "I recognize that this business of the additional three is a complication. And we apologize for that. But the feeling was that there needs to be an encouragement for organizations to customize, if you will, their list because there may be, usually will be, certain terms or abbreviations that are somewhat unique to that organization that really ought to be part of that process. And it's too easy to say, 'We'll just do the nine' and let it go at that."
The decision to require organizations to add at least three items to JCAHO's list was made during the executive committee's October 23 meeting, Croteau said. But through "some internal miscommunication," which he described as ironic, not all the information about the more stringent goal for communication was initially posted on the Web page.
Umhoefer said an organization's root cause analyses of serious adverse events could be used to identify abbreviations, acronyms, and symbols for addition to the do-not-use list. Also, communication shortcuts that nearly led to medical errors should also be considered.
"It might be different in a psych[iatric] hospital versus a neonatal intensive care unit," she said in explaining why each organization should look internally for ideas.
Umhoefer acknowledged that an organization could choose the easy route by expanding its do-not-use list with abbreviations that are rarely used. But, she said, that strategy raises questions about the organization's safety culture.
"Are they invested in making these changes for the benefit of patients' safety? Or are they just trying to meet . . . an accreditation standard so that they can check it off their list and say that they got it done?"
Challenges. Of the nine abbreviations JCAHO selected for organizations' minimum do-not-use list, Kienle said "Q.D." presents the greatest challenge for pharmacy.
"I think it will be a little bit difficult for some pharmacies to eliminate the Q.D. because it's so ingrained, but I think everyone realizes that it's something that has to be done," she said.
Also challenging, she said, will be eliminating dangerous shortcuts from printed and electronic formats.
JCAHO said its requirement that organizations eliminate certain abbreviations, acronyms, and symbols applies in 2004 to all handwritten patient-specific documentation and, starting in 2005, extends to all media on which patient information is documented.
Umhoefer said pharmacy personnel need to explore and evaluate the configuration of their pharmacy information system and then start making changes in the setup.
"If they don't know whether they can do that, they should be contacting their suppliers . . . because they should be knowledgeable about that and help out," she said.
McKesson's software implementation teams, Umhoefer said, have received information about the new JCAHO requirement so they can help new users configure their software.
Pharmacies, however, should already have an employee or information systems manager assigned to software maintenance because of the ongoing need to add new drugs and prices, she added.
But software configuration is only one of a variety of issues requiring attention.
"It does very little good to have preprinted order forms that still say Q.D. and to go into another system" and find every Q.D. has been replaced with daily, Umhoefer said, emphasizing that it is important to have consistent, standardized resources throughout an organization.
She also said organizations must devise a plan for dealing with medication orders that reach the pharmacy and have one of the forbidden abbreviations.
"What happens when that order comes down for . . . stat heparin that's got a U on it?" she asked. "And what do you do? What's the expectation as it relates to getting that order, taking care of that patient in an emergent situation? What's the follow-up procedure?"
Recognizing that 100% compliance with the new requirement will not occur the first year, JCAHO said any use of a forbidden abbreviation, acronym, or symbol in patient-specific documentation in 2004 must be followed by confirmation of the intended meaning before someone carries out the order.
Croteau said JCAHO expects that users of prohibited abbreviations will be contacted for clarification and told not to use the shortcut again. "The only exception is when the intent, in fact, is not ambiguous—it's quite clear what's intended—and the delay imposed by contacting the prescriber would be detrimental to the patient."
Organizations, he said, must decide how they will monitor the act of clarification. "They should decide whether they're going to require some sort of notation saying that the prohibited abbreviation had been clarified with the prescriber."
Kienle said JCAHO's suggestion to use "mcg" instead of "ug" to abbreviate microgram is not without its own danger.
"I think it has a significant potential" to be mistaken for "mg," the abbreviation for milligram, she said. "I think a lot of places have to make the effort to say 'write out micrograms, don't abbreviate it at all.'"
Whose responsibility? Umhoefer said she expects the new JCAHO requirement to be discussed by pharmacy and therapeutics (P&T) committees, medical staff committees, and medical records departments. Many approvals will be needed, she said, followed by a lot of training and education.
She said a big hurdle to overcome will be changing the behavior of people who have the attitude "I've been using Q.D. forever and ever, and I've never had a problem with it."
But because the new requirement is related to medication use, Umhoefer said, "I think pharmacists need to take a leadership role in this. . . . But they don't own it."
Kienle shared Umhoefer's sentiment.
JCAHO's new requirement "is not just a drug issue," Kienle said. "It's not just a medication order issue. It involves all orders in an organization."
She viewed responsibility for achieving compliance with JCAHO's patient safety goals as involving entire organizations, not solely pharmacy departments.
"I think they have often been seen as the leader in this effort since the primary focus has been . . . medication orders," Kienle said. "Pharmacy, in most cases, has been leading the charge and has been the conduit for taking this [issue] to the P&T committee and to the medical staff to make sure the hospital's policies and guidelines are being followed."
JCAHO's Croteau said the accrediting group did not explicitly name a department or person responsible for the do-not-use list because every facility is different. "I think whatever group or person in the organization that deals with standardizing terminology and other communications, record-keeping issues, would be the people to deal with this."