From the August 12, 2004 issue
How is your organization enforcing compliance with
the Joint Commission's National Patient Safety Goal (2b),
which requires the elimination of dangerous abbreviations
and dose expressions? This seemingly simple practice change
has the potential to prevent untold tragic injuries - such
as a brain injury that a patient sustained when a nurse misinterpreted
a "U," intended to mean "units," as a
zero. Yet it seems that getting approval for a list of prohibited
abbreviations and dose expressions is one thing; implementing
it is another. Not to minimize the difficulty with making
any system-wide change, it's still hard to understand why
any practitioner might be reluctant to comply. So, is it simply
a matter of not knowing the harm that can follow the use of
certain abbreviations, longstanding habits, or something else?
To address the difficulty with achieving compliance with
this important initiative, the Joint Commission offers several
helpful tips (see www.jointcommission.org).
Most focus on educating, advocating, and reminding staff.
Only one tip seems to be directly related to enforcement: "Direct pharmacy not to accept any of the prohibited
abbreviations. Orders with dangerous abbreviations or illegible
handwriting must be corrected before being dispensed." A corollary to that - enlisting nurses to help notify physicians
- may also be employed. Unfortunately, following this advice
has spurred numerous reports of burdensome workloads for
those making the calls, and strained relationships between
the medical staff and nurses and pharmacists who are being
forced to police the issue.
For example, some physicians are so disturbed by the calls
that, in turn, they refuse a request to change the order
that contains a prohibited abbreviation or dose expression.
As a result, another attending physician must be called
to obtain the necessary orders. A mid-sized hospital reported
that, during April-June, pharmacists had made 519 calls
to physicians for just one abbreviation, "QD." Additional calls had been made for other prohibited abbreviations,
too. But the results so far have been less than favorable.
In fact, some prescribers no longer answer pages from pharmacy,
believing it's just another call about a prohibited abbreviation!
Also, the time interval for answering the page has been
notably extended, thus delaying drug therapy. To make matters
worse, during a Joint Commission mid-cycle survey, a surveyor
told one hospital that they could still be cited for non-compliance,
despite frequent calls to prescribers, because a few prohibited
abbreviations had been found in medical records.
The real issue here is that enforcement of prohibited abbreviations
requires more than asking pharmacists or nurses to alert
prescribers to lapses in compliance. It's a system-wide
problem that requires peer-to-peer interaction along with
full support from hospital and medical staff leadership.
Hospitals that have been working on this initiative relentlessly
for years report that the most effective way to enforce
physician compliance is to make it a physician-owned process.(1,2)
When educational efforts failed to produce significant change,
these hospitals pursued operational changes, such as preprinted
orders, targeted pages, and email reminders, to initially
improve compliance. Then, after enacting a zero tolerance
policy, medical staff leaders interacted with physicians
who were non-compliant. Pharmacists and nurses still played
a role in collecting data about non-compliance, and even
notifying individuals when there was a lapse in policy.
But the medical staff stepped up to the plate and addressed
all issues of repeated physician non-compliance.
The elimination of error-prone abbreviations also needs
to be pervasive both within organizations and externally.
You can't expect practitioners to eliminate the use of specific
abbreviations if they still appear on computer screens,
drug labels, drug administration records, preprinted orders,
and other forms of communicating drug therapy. Likewise,
professional journals, academic facilities, medical device
and computer software vendors, and the pharmaceutical industry
need to embrace this issue and make it a high priority.
So far, many have not!
In November 2004, the Joint Commission plans to convene
a National Summit on Medication Abbreviations with
participation from leading physician, nursing, pharmacy,
administrative, and academic research organizations. Recognizing
the challenges that healthcare organizations face in eliminating
the use of dangerous abbreviations, the goal of the summit
is to define the scope of the problem, discuss the need
for a universal "do not use" list of abbreviations,
and explore how healthcare organizations can successfully
address the problem. A consensus list of certain abbreviations
to eliminate is the intended end product. However, ISMP
is hopeful that the summit will also elicit: (1) proficient
enforcement strategies that have been culled from successful
organizations; (2) realistic timeframes and objective criteria
for surveyors' assessment of compliance; and (3) learning
about new types of errors that could result when prohibiting
the use of abbreviations (see the Safety Brief, New sources
of error, to the right for examples).
(1) Traynor K. Enforcement outdoes education at eliminating
unsafe abbreviations. Am J Health-Syst Pharm 2004;
16:1314-5. (2) Joint Commission Resources. A guide to JC's
medication management standards. Oakbrook Terrace, IL: JC;
2004. p. 142-6.