• E-mail
• Print
• RSS

A Texas hospital is scrutinized for its unacceptable drug abbreviations

Accreditation Connection, June 1, 2004

Surveyors closely examined the use of unacceptable drug abbreviations during the November 2003 survey of the Institute for Rehabilitation and Research in Houston.

Up until November, when the JCAHO issued its minimum list of nine dangerous abbreviations, acronyms, and symbols, the accreditor had required hospitals to develop their own lists. Surveyors look for 90% compliance on this standard.

As well as meeting 90% compliance, hospitals surveyed in 2003 must adopt a plan for continued improvement by the end of 2004.

The Institute received a Type I on the use of abbreviations because surveyors caught too many instances of nursing and physician staff using "QD" (or "qd") and "D/C," according to Lourdes M. Cuellar, MS, RPh, FASHP, the Institute's pharmacy director. QD means every day and D/C means discharge or discontinue.

She wasn't too surprised, since it's nearly impossible to achieve a perfect score in an area where physicians and nurses can no longer use familiar abbreviations, acronyms, and symbols.

"I don't know of a hospital that scored perfectly in this area, and I talked to a lot of pharmacy directors about this issue," she says. "It just takes time."

The Institute created its own do-not-use drug abbreviations, acronyms, and symbols list shortly after the JCAHO announced National Patient Safety Goal #2 in July 2002. Staff looked at the past two years of medication variances and adverse drug events to learn which abbreviations had led to potential errors and, thus, place them on their list, Cuellar says.

The hospital started with 12 unacceptable abbreviations, symbols, and acronyms, which in hindsight were too many, Cuellar said. Before the JCAHO issued its own list, the hospital had narrowed it down to eight.

Luckily, many of the JCAHO-mandated abbreviations were already on the institute's list, Cuellar says. Surveyors asked to see the Institute's list and whether the medical staff or appropriate body approved it.

TIP: Start with the JCAHO's mandated list and then work from there. "If you make your list too large you hurt yourself more than you help, since it's hard to change practices-particularly with caregivers who have used certain abbreviations for 20 or more years," Cuellar says.

Note: Effective in April, the JCAHO will require hospitals to adopt three additional do-not-use abbreviations from another list of seven. To view these, check out the National Patient Safety Goals frequently asked questions, posted at www.jcaho.org.

On the morning of the second day of the survey, surveyors pulled about 30 patient charts. In particular, they looked at the use of abbreviations QD and D/C, Cuellar says. Luckily, those were already on the Institute's unapproved list.

"They were fair, but you must show that nine out of 10 times you follow your policy on which abbreviations not to use," Cuellar says.

A surveyor noticed that on the pediatric unit, a physician had written QD. A nurse spotted the prohibited abbreviation and asked the physician to clarify the order.

"The physician [confirmed that] he meant 'every day,' which the nurse wrote on the chart above the abbreviation," Cuellar says. "As long as a staff member clarifies a prohibited abbreviation, the JCAHO finds this acceptable."

TIP: On a brightly-colored card, list your hospital-approved unacceptable abbreviations and attach the card to the front of each patient chart. "When physicians and nurses open the chart, it's the first thing they see," Cuellar says.

Surveyors also wanted to see that staff had monitored compliance with the hospital policy on unacceptable abbreviations for a minimum of a year prior to the triennial survey.

Remember: The JCAHO does not have a data collection requirement, but you need to understand and demonstrate your compliance. See the Institute's unacceptable abbreviations policy below.

Note: Effective January 1, standard IM.3.10 requires hospitals to create a do-not-use list. Surveyors will score the handling of unacceptable abbreviations only in relation to the standards compliance assessment. In the National Patient Safety Goal section of the quality report, the JCAHO will include an organization's performance related to each goal requirement.

The JCAHO will note National Patient Safety Goals performance as either "similar to the performance of most JCAHO-accredited organizations," "below the performance of most JCAHO accredited organizations," or "no data is available for this measure," according to the American Hospital Association's December 2003 JCAHO Update posted on its members-only Web site.

It's not just physician orders that surveyors examine-it's the entire chart. Any page on which handwritten drug orders exist-progress notes, operative records, nursing notes, etc.-falls under compliance with this goal, Cuellar says.

The only current exceptions include printed forms for the medication administration record (MAR) and lab reports.

Because changing behaviors with regard to drug abbreviations affects so many staff members and the JCAHO scores this so stringently, the Institute's pharmacy staff increased its education measures to ensure that staff members comply.

For instance, Cuellar created a "Dear Doctor" letter to educate physicians who continue to use unacceptable drug abbreviations. (See the letter in the PDF of this issue.)

This tactic impressed surveyors, since the letter goes beyond just reprimanding physicians and offers educational details about how these abbreviations can be misinterpreted.

"It gives direct feedback to physicians," Cuellar says.

The pharmacy department continually looks at trends to monitor the use of unacceptable abbreviations. For example, in the third quarter of 2003, pharmacy staff discovered that three medication errors occurred when staff misinterpreted a QD as "qid," Cuellar says. Qid means "four times daily" as opposed to QD, which means "daily."

Pharmacy staff sent out a patient safety alert e-mail stating their findings and urging extra caution. "If we see a pattern, we bring it to the attention of everyone involved," Cuellar says.

Note: This is also good information to send to the medical staff, to hammer home the danger of using "qid."

During another quarter, pharmacy staff focused on the use of D/C. They noticed that physicians tended to write D/C followed by a list of medications in patient charts. Some staff thought the abbreviation meant "discontinue," rather than its actual meaning, "discharge," because it followed the list of drugs. Pharmacy staff shared this revelation with involved staff.

Pharmacy staff also meet with physicians and residents to discuss the prohibited abbreviations. Using real handwritten orders with the patient and physician names blacked out, they demonstrate for physicians and residents the possible and real errors that happen.

This discussion makes changing behavior a bit easier by helping physicians and nurses understand why they can't use the abbreviations that are so familiar. "It's more relevant for them," Cuellar says.

This tactic seems to have worked. The compliance rate of those who stopped using abbreviation D/C went from 4% to nearly 90%, she says.

Cuellar's department tells nurses and unit secretaries to look out for bad abbreviations. If unit clerks spot an unacceptable abbreviation, they page the physician and tell a nurse that they have done so. The nurse knows to clarify the order before it goes to the pharmacy.

This duty does place more work on nurses, who must also act as referees. However, during discussions on how to prevent medication errors due to poor handwriting and careless use of abbreviations, nurses agreed that they must take on this task to benefit the entire hospital.

"They wanted to take a proactive stance and look at it positively," Cuellar says.

In addition, pharmacy staff go on rounds with residents, medical and pharmacy students, and physicians each week. While typically on-site to perform drug interventions, pharmacy staff also focus on the use of drug abbreviations, acronyms, and symbols. When they see a physician writing a drug order, pharmacists check to ensure that he or she records the correct abbreviation, acronym, or symbol.

"If a patient is being discharged, they will remind them to write out D/C," Cuellar says.

Some physicians do resist changing behaviors, saying they have written QD for many years and won't change their practice, Cuellar says. If an error occurs as a result, Cuellar meets individually with the physician and shows him or her the drug order that led to the error and explains the consequences.

For example, a nurse once misinterpreted QD on the MAR as qid. Cuellar showed the physician the order. The physician was surprised to recognize that he may have made the same misinterpretation error, which helped the message to really sink in.

"When you just mandate, it's more adversarial, but if you show why it's important to do something, it's a lot more collegial," she says.

"What has come across is the interpretation that 'I never had a problem,' but in reality, it's never been brought to their personal attention."

• E-mail to a Colleague
• Print
• RSS
• Archive