Accreditation

Eliminating dangerous abbreviations is a long-term project

Accreditation Connection, April 12, 2004

When the Madison (WI) Patient Safety Collaborative launched its first improvement project in December 2000, the group wanted to begin with something simple that would show quick gains and sustain momentum: getting physicians and staff to stop using certain abbreviations. One year later, the organization realized just how "simple" it would be.

"We weren't thinking at the time that it would involve changing ingrained behaviors," says Amanda Borgsdorf, MHSA, the collaborative's coordinator.

Telling physicians what to do is never easy. Getting them to stop using abbreviations they've been jotting down since medical school is even harder.

"Reducing dangerous abbreviations has been one of the more deceptively difficult projects we've done," says Andrew Kosseff, MD, FACP, medical director of clinical system improvement for SSM Healthcare (SSMHC), headquartered in St. Louis. One of SSMHC's Madison hospitals, St. Mary's Hospital Medical Center, participates in the collaborative.

That's a powerful statement, considering its source; SSMHC is one of the most lauded healthcare organizations in the country. In 2002, it was the first recipient of the Malcolm Baldrige National Quality Award, which recognizes quality and performance excellence.

So if your organization is fumbling at reducing certain dangerous abbreviations, it is not alone. JCAHO surveyors indicate that most accredited hospitals do not fully comply with the JCAHO's second National Patient Safety Goal.

The goal in part requires you to improve communication by standardizing the abbreviations, acronyms, and symbols that care providers should and should not use within your organization.

Consider this: Orders that contain confusing abbreviations take longer to process and can impact patient safety, length of stay, and clinical outcomes if they are misinterpreted.

Goal: Completely eliminate four confusing abbreviations and symbols

Three of the collaborative's seven member hospitals chose the following common abbreviations and symbols. Their goal was to eliminate them (and in one case, always use them) for all inpatient medication orders during 2003.


QD: Eliminate this shorthand and instead write out the word "daily"


U: Eliminate this shorthand and write out the word "units"


Trailing zeros after a decimal point: Don't use them


Leading zeros before a decimal point: Always use them

Find it and fix it

Each organization collected baseline data that reflected how many times each abbreviation appeared (or, in the case of leading zeros, didn't appear) on inpatient medication orders in one day.

Then, key administrators, physicians, nurses, and pharmacists at each hospital met to brainstorm possible interventions.

Several months after launching an intervention, each hospital measured its success by again counting how many times the abbreviations appeared correctly on inpatient medication orders for one day.

If the intervention was successful, the hospital kept it in place. If the intervention wasn't successful, the hospital considered ways to adjust it. Members of the collaborative met monthly to share their successes and failures.

To the organization's surprise, the hospitals had a successful first quarter, followed by other quarters that showed backslides.

For example, most hospitals began the initiative with the abbreviation "u" present in an average of 45% of inpatient medication orders. That rate fell to about 8% in the first quarter, but spiked back up to 38% in the second quarter. It dropped down to 4% in the third quarter, where it remains.

When this happened, collaborative members gave each other advice, says Kosseff. "That kind of information exchange is very important," he says. "That's one of the biggest advantages of the collaborative: No one is the absolute expert."

Lesson #1: Don't ease off the education. The backslide was likely due to a decreased focus on education for physicians, says Borgsdorf (see "Seven interventions that work" on the right for a list of the collaborative's most successful interventions).

"We can't just focus our education efforts on this for six months and then back off," she says. "We've got to keep the attention on it by continually mentioning it during meetings, in staff newsletters, and on posters hung around the hospital."

Lesson #2: Don't forget to educate nurses, physician assistants, and nurse practitioners, who either write orders, document them in medical records, or take verbal orders from physicians.

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