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Direct Feedback Program Gets to Heart of Improved Order Writing

Linda R. Harteker

Illegible or incomplete medication orders pose one of the chief obstacles to safe medication use. These orders are easy to identify but often hard to fix. Some physicians are unaware of order-writing protocols; others have poor handwriting. Few take time to check over an order for clarity before passing it on.

The medication safety team at Children’s Hospitals and Clinics in Minneapolis and St. Paul, Minnesota, recently started a program to improve the clarity and accuracy of medication orders. Under the program, physicians receive direct written feedback on their order-writing practices. The problems are identified by pharmacists, noted on a specially designed form, and mailed to the physicians by the two hospitals’ quality resources department. Initiated in January, the program has yet to be evaluated; however, initial reports are promising, says pharmacy director Mark Thomas.

A patient-safety-first culture. The effort to improve physicians’ orders comprises one part of the "Patient Safety First" agenda adopted by Children’s in 1999. Thomas says the agenda seeks to "raise the bar for the health care industry." Staff members are committed to creating a culture in which patient safety would be the number one concern.

Planning for the handwriting project began last year, spearheaded by the medication safety team, a group of physicians, nurses, pharmacists, and other health care providers from the health system who meet regularly to detect and eliminate system defects that may threaten patient safety. Thomas chairs the team with pediatrician Bruce Bostrom.

Chart audits revealed that poorly written or incomplete orders were an ongoing problem, Thomas says. The team knew of several ways to approach the problem.

Traditional methods had already been tried. A few years ago, the hospitals launched an educational program designed to increase awareness of the need for clear orders. Educational bulletin boards showing examples of poor ordering skills were prepared and displayed throughout the organization. More recently, the pharmacy department issued a booklet on safe medication practices for the professional staff.

These actions were worthwhile, but their effectiveness was limited. Thomas proposed a new idea: a system that would provide direct and individualized written feedback to prescribers about their order-writing habits.

Under this new system, pharmacists are trained to be on the lookout for poorly written or incomplete orders. When such an order is detected, the pharmacist photocopies it, highlights the problems, and attaches it to a reporting form. At the top of the form is a letter addressed to the physician; at the bottom is a three-column table. In the table’s left column is a list of unsafe order-writing practices (e.g., failing to write a 0 before a decimal point for doses less than 1). The middle column shows an example of the unsafe practice. The third column provides an example of the preferred practice. The pharmacist simply checks the particular fault or faults identified on the physician’s order, clips the two sheets together, and forwards them to the quality resources department, which mails the set to the physician.

The program targets medical residents and full-time staff physicians. Information on safe order-writing practices has been incorporated into the residents’ orientation sessions. Faulty transcribing practices of nurses and pharmacists are also identified by the program; they, too receive feedback letters.

Fine-tuning for greater efficiency. Minor adjustments have been made in response to initial feedback, Thomas says. For example, some pharmacists found the forms burdensome to use daily. As a result, the team started a problem-of-the-week approach. Every Wednesday, a different source of problematic order writing is highlighted. Instead of having to consider every potential source of error, the reporting pharmacists can focus on a single problem.

A second adjustment, made at a physician’s suggestion, was to modify the requirement that dosages be routinely expressed in terms of milligram per kilogram and total dose. Now only doses for high-risk drugs must be expressed in both formats, Thomas says. Commonly used medications such as acetaminophen can be expressed in only one format.

Reasons for optimism. Thomas and his team did a baseline audit of 50 charts at each hospital at the time the program began. An equal number of charts will be reviewed this spring, he says, in order to assess the impact of the program. In the meantime, Thomas is confident that the program has merit.

First of all, the forms are being used—a clear sign that the pharmacists consider the preprinted sheets an effective means of communication. By the end of February, about 140 letters had been sent.

One key reason for the pharmacists’ support, says Thomas, is that it enables them to identify problems without assuming a confrontational or "bad cop" role. "Our decentralized pharmacists have done a lot to establish good working relationships with the physicians, and we didn’t want to jeopardize that role," he says. "Pharmacists already do a fantastic job clarifying confusing orders, catching mistakes, and communicating these problems to physicians, but we really never focused on the source of the problem: sloppy handwriting and poor ordering habits."

The program is also easy to operate. The problem-reporting form had to be designed; other than that, the program tapped into existing resources. The "engine," Thomas says, is the quality resources department, which was equipped to send messages to staff. Safe medication use is, of course, a key concern for the medication safety team, which oversees the project.

Third, the program provides feedback in a nonthreatening way. The hope is that the written warnings will increase prescribers’ awareness and spark change. At this point, the team has no plans for taking more stringent action against repeat offenders. "We want to allow the process to work through," Thomas says.

Finally, the program is supported by a comprehensive safety agenda. "We’re not a large hospital system. We have around 27 full-time-equivalent pharmacists for both hospitals. We don’t have unlimited resources," Thomas says. "But what’s important is that many staff are involved at various points in our safety agenda. It’s an approach that can work at any institution."