Nursing

Look beyond medication orders for unapproved abbreviations

Nurse Leader Weekly, October 25, 2004

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Although unapproved abbreviations may appear most frequently in medication orders, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) bans nine abbreviations in all clinical documentation, including patient medical records.Don't forget to check patient medical records for the JCAHO's unapproved abbreviations and monitor compliance.

Unapproved abbreviations may appear in numerous clinical documents, says Liese Harter, quality-improvement specialist at Meriter Hospital in Madison, WI. They include the following:

* Patient profile/nursing admission assessment
* Anesthesia history
* Blood-glucose monitoring flow sheets
* Medication administration record
* Progress notes

Staff at Nason Hospital in Roaring Spring, PA, review approximately 60 patient records each quarter for unapproved abbreviations, says Faith Neal, patient-safety officer, privacy officer, and health-information management director.

The team of pharmacists, dieticians, nurses, lab staff, and others look at patient charts from all different units. When staff find an unapproved abbreviation in a patient's record or a medication order, they send a copy of the page to the staff member who wrote the abbreviation with a reminder not to use it again, Neal says.

The review began more than a year ago as a one-time pharmacy audit of medication orders. But the process was too time consuming to conduct in addition to the pharmacy's daily tasks, so the hospital incorporated it into the organization's chart review, Neal says.

There does not seem to be any well-known, accumulated data linking unapproved abbreviations to medication errors, says Amanda Borgsdorf, MHSA, coordinator of the Madison Patient Safety Collaborative in Madison, WI. Presenting physicians and staff with real-life examples that link medication errors to unapproved abbreviations is the best way to make them comply with the JCAHO requirements, Borgsdorf says.

"What works the best is if you can remind them at that instance," Borgsdorf says.

Nason Hospital's pharmacist leads a monthly patient-safety forum, and if an incident involving a medication error and an abbreviation occurred, that would become a discussion topic during the forum, Neal says.

Meriter Hospital gave physicians and nurses pens that had the unapproved abbreviations list printed on them. Physicians and nurses would see the abbreviations every time they wrote an order or made an entry into the medical record, Harter says.

"What can we get in their line of sight at that moment?" Borgsdorf asks. "Maybe since they're writing with the pen, they'll see it that way."

Source: Briefings on JCAHO (April 2004), published by HCPro, Inc.

 



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