Eliminating the use of dangerous abbreviations

The MPSC project focused on four targeted abbreviations: qd, u and the inappropriate use of leading and trailing zeros w/ decimal point.

Baseline data was collected at each institution and shared followed by the use of improvement cycles. Each member enacted interventions thought to be most appropriate and effective for the respective organization and, after several months, data was again collected and analyzed. 

Members then determined whether interventions found to be effective at one organization could be adopted by others to yield greater results in the next improvement cycle. 

Some of the specific tactics used by the 4 hospitals in this collective endeavor include:

Educational/awareness interventions

• Sent letters on error-prone abbreviations to physicians and nurses from medical leadership/physician influentials.
• Placed educational articles on topic in internal publications, posters around the organizations, signs in nurse/physician restrooms and screensavers on computers reminding about error-prone abbreviations.
• Held discussions on the topic at key organization meetings.
• Incorporated education on error-prone abbreviations and medication ordering requirements into new employee orientation for pharmacists, nurses and physicians.
• Placed florescent stickers on charts with error-prone abbreviations in orders.
• Created an on-line Power Point module on topic, which was made an annual requirement for faculty and house staff. E-mail reminders used to contact individuals that have not completed the module.
• Held a Medication Safety Week that had activities addressing dangerous abbreviations.
• Developed an abbreviations pocket card listing 'error-prone abbreviations' and the preferred alternative and distributed to house staff, attending physicians, new residents, and 3rd year medical students.

Structural interventions

• Created a separate order form for medications including a 'grid' to increase legibility, separate columns for medication, dose, route, frequency, and indications/other.  Section on the form highlights inappropriate abbreviations and examples of correctly written orders.
• Included a laminated 'placemarker' (bookmark) that goes in the patient chart in the orders section between the medication and other order sheet (forms face each other for writing ease) that highlights inappropriate abbreviations.

Monitoring/Auditing activities

• Performed monthly or quarterly audits with reports to the physicians, nurses and administrative groups.
• Used Vice Presidents for Medical Affairs to follow-up with 'frequent offenders'.
• Had health unit clerks fill out an audit form each time they received an order with an inappropriate abbreviation. VPs for Medical Affairs collected forms daily and made immediate contact with prescribers who used targeted abbreviations.

Monitoring/Auditing activities

• Spot checked orders and prescribers who used an inappropriate abbreviation received a letter from department chair, VP for Medical Affairs or physician leader. 
• Posted results/feedback in the physician lounge, restrooms after each audit.

Enforcement Activities

• Employed a “hard stop” to orders with error-prone abbreviations. If medication order received with targeted abbreviation, pharmacists require that the order be re-written by the prescriber (verbal clarification allowed if off unit & documented).

Lessons Learned

• Need to include nurses, physician assistants and nurse practitioners besides just focusing on physicians.
• Entity standing orders, protocols, care pathways may contain dangerous abbreviations- need to sanitize.
• Need to catch new house staff and residents.
• Information systems often contain inappropriate abbreviations in drop-down lists.
• Initiative needs “teeth” to help counter ingrained behaviors!

| About Us | Members | Patients | Providers | Projects |
| Publications | Resources | Contact Us |
| HOME |