Medication Order Writing amp the Do Not Use Abbreviations To enhance understanding of the linkages between medication safety and communication To ensure that all healthcare professional and associated staff are familiar with the DO NOT USE Dangerous Abbreviations and Symbols Dose De ID: 356312
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Slide1
Prescription for Safety:
Medication Order Writing & the “Do Not Use” AbbreviationsSlide2
To enhance understanding of the linkages between medication safety and communication.To ensure that all healthcare professional and associated staff are familiar with the “DO NOT USE: Dangerous Abbreviations and Symbols, Dose Designations” Materials from the Manitoba Institute for Patient Safety.
To review Manitoba cases of communication breakdowns in medication order writing related to dangerous, abbreviations and symbols.
To understand personal responsibilities related to safe medication practices.
Educational ObjectivesSlide3
The reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomesDefinition of Patient Safety
Davies JM, Hébert P, Hoffman C.
The Canadian Patient Safety Dictionary.
Ottawa: Royal College of
Physicians and Surgeons of Canada; 2003:12. Slide4
1999 Institute of Medicine Report (USA)
Medication errors - 106,000 deaths a year average of 300 deaths per day, every day.
Deaths from all major airline crashes in the U.S. average less than 300 annually
Media/Public attention on airline crash vs. med error deaths which are like an airline crash, but every day
.Slide5
Baker/Norton Study
7.5% of patients experienced 1 or more adverse events
36.9% of these patients experienced a highly preventable adverse event
9,250 to 23,750 deaths from adverse events could have been prevented
CMAJ 2004Slide6
Causes of Medication ErrorsHuman factors
COMMUNICATIONName confusionLabeling
Packaging
Retrospective analysis of mortalities associated with medication errors.
Am J Health-Syst Pharm – Vol 58 Oct 1, 2001Slide7
Causes of Medication ErrorsHuman factors
COMMUNICATIONName confusionLabeling
Packaging
Retrospective analysis of mortalities associated with medication errors.
Am J Health-Syst Pharm – Vol 58 Oct 1, 2001Slide8
Verbal Communication FailureA nurse in a busy emergency department received a verbal order for digoxin and wrote the order as it was ‘heard’.
The nurse intended to give the higher end of the dosing range as the patient was very unwell.
Fortunately, an error was avoided when it was identified through further communication with other health care providers that the intent of the prescriber was Digoxin 0.125 mg po daily.
“Digoxin .1 to 5 mg po daily
”
WRHA ExampleSlide9
Written Communication FailureCoumadin 1mg or 10mg? Patient received 10mg when 1mg was intended.
Risperidone
1.0mg or 10mg? The intent was 1mg.
Intended dose of “0.4mg” of
vincristine
but was interpreted as 4mg from medication order. Should be written as 0.4mg.
WRHA and FDA ExamplesSlide10
Abbreviations and ErrorsTextText 2Slide11
Abbreviations and ErrorsTextText 2Slide12
MK is a 67 year old male with a 10 year history of type 2 diabetesHe has recently been started on insulin and has been reasonably well controlledHe seen in the ER and diagnosed with pneumonia. He is started on IV levofloxacin and transferred to a medical ward where the following order is written:
Case ConsiderationSlide13
Case Consideration
Entered in the pharmacy system with a frequency of once daily
Nursing Medication Administration Record reflects a frequency of QID (four times daily).
80% of errors occurred when the prescription was written but 20% occurred afterwards (ex. transcription)
Joint Commission Journal of Quality and Safety 2007Slide14
An assessment of MK’s blood sugar shows a fasting blood sugar of 27The physician on rounds suggests an additional dose of regular insulin and writes the following order
Case ConsiderationSlide15
Case ConsiderationThe prescription for 6 units of regular insulin was misinterpreted as “60”
60 units of regular insulin was givenMK became hypoglycemic and unresponsive but made a full recover after the administration of IV glucose
Recommendation: Write out “units” to avoid confusionSlide16
MIPS SolutionsPatient Safety is in YOUR Hand!
Posters to address specific abbreviationsDO NOT USE: Dangerous Abbreviations, Symbols and Dose Designations
Adapted from Institute for Safe Medications Practices (ISMP) listing
Endorsed by Colleges, WRHA and is in use in some form in all RHAs in Manitoba
Posters are Copyright of the Winnipeg Region Health Authority
Slide17Slide18Slide19
Beyond Abbreviations
Posters are Copyright of the Winnipeg Region Health Authority
Slide20
Why?Public awareness and expectation that all reasonable measures are taken to ensure safety
Professional Responsibilities
Medical-Legal issuesSlide21
Why Else?
Accreditation Canada Required Organizational Practice 2009The organization has identified and implemented a list of abbreviations, symbols, and dose designations that are not to be used in the organization.
Order Writing Standards
Most RHAs have already adopted Order Writing Standards that address the issue of abbreviations and other order writing practicesSlide22
“When anyone asks me how I can best describe my experience in nearly forty years at sea, I merely say, uneventful. Of course there have been winter gales, and storms and fog and the like. But in all my experience, I have never been in any accident ... or any sort worth speaking about. I have seen but one vessel in distress in all my years at sea. I never saw a wreck and never have been wrecked nor was I ever in any predicament that threatened to end in disaster of any sort."
Edward J. Smith, 1907
Captain, RMS Titanic, 1912Slide23
Changing EnvironmentSet a personal example
Consider standard orders, care maps and guidelines
Medication Labels and Software
Advertising
Journal Articles
Trade JournalsSlide24
Recommendations for Healthcare Professionals
Avoid writing ambiguous orders with Do Not Use abbreviations in written ordersSafety First – seek clarification of any order that is unclear or ambiguous
Work with computer software vendors to make changes in electronic order entry programs.
Consider Computerized Physician Order Entry (CPOE) Systems that avoid both handwriting challenges and the use of unclear abbreviations (ex.
CancerCare
MB)
Ensure all staff have access to the MIPS “Do Not Use” Documents
Include MIPS “Do Not Use” information in training of healthcare employees and studentsSlide25
Nurses
Pharmacists
Physicians
Medication Safety
Team Approach
Management
Support StaffSlide26
Educational Outreach/AwarenessLocal ChampionsMandatory Education
Audit and Feedback
Challenges
Habits of order writing are deeply ingrained
Perceived lack of importance
Carrot and/or StickSlide27
“Enforcement outdoes education at eliminating unsafe abbreviations”AJHP 2004; 61: 1314-1315.
Anecdotal discussion with 3 major healthcare facilities in the United StatesAll conducted extensive educational outreach
None showed any marked improvement in abbreviation use
Two of the facilities implemented strategies that lead to improvements in order writing
…and/or StickSlide28
Strategy #1All medication orders with unacceptable abbreviations were considered to be invalid and required that the prescribers rewrite the orders
Strategy #2
Developed a physician-owned process. They had to manage it, and they had to enforce it
…and/or StickSlide29
MIPShttp://www.mbips.ca/wp/initiatives/patient-safety-is-in-your-hand/
FDAhttp://www.fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm
ISMPhttp://www.ismp.org/tools/abbreviations
Health Canada
http://www.hc-sc.gc.ca/dhp-mps/medeff/advers-react-neg/index-eng.ph
p
Web ResourcesSlide30
Post Test – Review Your Knowledge of “Do Not Use” Abbreviations http://www.mbips.ca/wp/hidden-link/exam-test-page/
Accreditation
form will be emailed upon completion of post test
Pharmacists: Accredited by MPhA
#
30196M
Nurses: Participation in this self-directed learning activity may fulfill the requirements of the College of Registered Nurses of Manitoba Continuing Competence Program.
Please retain post test as record of self directed learning
Professional
Develoment
/CEU