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Enforcement Outdoes Education at Eliminating Unsafe Abbreviations

Kate Traynor

Midway down the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) list of tips for eliminating dangerous abbreviations, acronyms, and symbols is perhaps the most effective advice of all:

"Direct pharmacy not to accept any of the prohibited abbreviations. Orders with dangerous abbreviations or illegible handwriting must be corrected before being dispensed," the accrediting agency states on its Web site.

Mark Thomas, director of pharmacy at Children's Hospitals and Clinics in Minneapolis, Minnesota, said that his institution started trying to eliminate unsafe abbreviations from medication orders about three years ago, before JCAHO took up the issue as part its National Patient Safety Goals.

"We've tried everything" to eliminate unacceptable abbreviations over the years, Thomas said. He added that Children's worked on the issue in collaboration with area hospitals as part of the "Safest in America" initiative. Formed in 2001, Safest in America is a consortium of Minnesota hospitals and health systems that have adopted common practices with the goal of achieving universal improvements in patient safety.

Thomas's catalog of strategies that coalition members have used to reduce unacceptable abbreviations includes feedback letters to prescribers who use the banned abbreviations, one-on-one educational sessions with prescribers, newsletters, preprinted lists of the abbreviations and their alternatives on orders, chart notices, sticky notes, and positive reinforcement when prescribers do well.

He said that Children's even had pharmacists on patient units at the 173-bed hospital wear T-shirts with "a list of the good abbreviations on one side and a list of the bad abbreviations on the other."

"We've never relented on this," Thomas said. Yet, he added, the consortium "never really saw much improvement, no matter what type of things people did" to eliminate the abbreviations.

"What we found at Safest in America is that education doesn't work," Thomas said. "It's not sustainable. You'll see some improvement, but it doesn't eliminate the problem."

Ultimately, the executive officers of the coalition's hospitals decreed that, starting April 1 of this year, each facility would consider medication orders with unacceptable abbreviations to be invalid and require that the prescribers rewrite the orders.

Thomas said that most of Children's physicians support and understand the importance of the policy and blame lapses on forgetfulness.

"It's just a bad habit that it's hard to get them to break," Thomas said.

Most prescribers, he noted, are cooperative when a pharmacist asks for an order to be rewritten. Those who refuse to redo an order are dealt with by the hospital's medical affairs office.

Thomas said that JCAHO has reacted favorably to the coalition's patient-safety initiatives, although none of the hospitals in the group have faced a JCAHO inspection since the accrediting organization started surveying for unacceptable abbreviations this year.

Nancy Granger, medication safety pharmacist at Fort Sanders Regional Medical Center in Tennessee, said that her 517-bed facility fared well on unacceptable abbreviations during an April JCAHO extension survey.

Granger said the surveyor "told the administrative staff that this was the first hospital she had been in where she hadn't seen any unacceptable abbreviations."

All orders with unacceptable abbreviations are routed through Granger's office, and she said that, although such orders have not been eliminated, they have dramatically decreased in number. At the time of the survey, about 6% of the hospital's medication orders contained an unacceptable abbreviation, down from 30% in January, Granger said.

Like Thomas, Granger said that Fort Sanders relied at first on educational efforts to persuade physicians to change their prescribing habits.

"We made posters that were placed in key areas for physicians: in the parking garage and in the physician lounge, in the dining area," she said. The abbreviations were also printed on tent cards in the physician dining area, which Granger said seems to be "a good way to distribute information" to physicians.

Granger said she sent letters to prescribers whose orders contained an unacceptable abbreviation and included in her correspondence a memo from the pharmacy and therapeutics (P&T) committee about the issue.

"But our rate of unacceptable abbreviations really didn't go down very much with that process," she said.

Next, Granger said, "our P&T committee made a recommendation that our medical executive committee accepted—that it had to be a physician-owned process. They had to manage it, and they had to enforce it. And that's when we really saw the good results," she said.

Granger said that, instead of sending letters to physicians who use unacceptable abbreviations, she began compiling a weekly list and sending it to the appropriate medical staff chairperson, who then contacted the physicians to resolve the issue.

"It seemed to work best that [the physicians'] colleague talked to them," she said.

Also contributing to the decrease in unacceptable abbreviations at Fort Sanders is a policy instituted in January requiring the pharmacy to call a prescriber for clarification any time an order with an unacceptable abbreviation reaches the pharmacy.

"We had several irate physician calls, from when we would call them in the middle of the night," Granger said. But as the physicians have realized the extent of the abbreviation problem and the need for consistency, she said, they have come to support the policy.

Granger said that some physicians and nurses had initially thought that the call to eliminate unsafe abbreviations originated with the pharmacy department.

"We had to do some education to explain why it was important and also that it was a Joint Commission standard now that we were required to meet," Granger said. "That did carry more weight. That, I think, caused the physicians to become more involved, once it became an accreditation standard."

Clinical Pharmacist Joanie Czerwinski of Marymount Hospital in Garfield Heights, Ohio, said she had initially worried how JCAHO surveyors would react to finding unacceptable abbreviations during the hospital's inspection in April.

"I was expecting them to be very strict, because I know they have a certain formula they use," Czerwinski said.

She said that the 312-bed hospital tackled the issue of unacceptable abbreviations by conducting a failure mode and effects analysis. From that analysis and elsewhere the hospital devised its educational strategies.

"We have a nice colored list of unacceptable abbreviations. We had it put in a sheet protector, and we put one in every patient chart," Czerwinski said. "We also printed the list on top of each physician order sheet . . . and on the progress notes."

The hospital also emphasized eliminating one unacceptable abbreviation each month.

"During that month, our pharmacists would collect orders that had that abbreviation," Czerwinski said. "What I would do then is forward it back to the original person who wrote that order . . . [with] a memo saying, 'This order has been identified as having at least one [unacceptable] abbreviation on it, here's what we recommend instead.'"

Czerwinski said the hospital has not had any complaints from physicians about the efforts to eliminate unsafe abbreviations. But she noted that, for diplomatic reasons, Marymount has not yet resorted to stopping orders that contain the abbreviations and calling physicians for clarification.

"It kind of causes that head-butting thing between pharmacy and physicians, and that's what we were trying to avoid here," she said.

Despite the hospital's efforts, Czerwinski said, there has been no noticeable decrease in the use of unacceptable abbreviations.

"It's been somewhat steady," she said of the number of orders with unacceptable abbreviations. "We're not seeing a huge difference. But we do know that, just kind of anecdotally, there are certain physicians who are no longer using abbreviations."

Czerwinski said that the hospital passed the portion of the JCAHO survey that dealt with unacceptable abbreviations.

"I think what happened is [JCAHO] saw all the steps we were taking" to eliminate unacceptable abbreviations, Czerwinski said. "We showed them that we were doing enough to address the issue."