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Hospital and medical staff leadership is key to compliance with JC dangerous abbreviation list

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 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).

References: (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.

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