Prohibited. Implementation & Results. Karen Horon, Director, Professional Practice. use space to insert photo or graphics

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1 Prohibited Abbreviations i Implementation & Results use space to insert photo or graphics Karen Horon, Director, Professional Practice

2 Objectives To learn how focused education and communication, rather than enforcement, can yield positive outcomes for safety initiatives. To extrapolate learnings from the implementation of this medication safety initiative to your site/sector/organization. 2

3 Why Target Dangerous Abbreviations? Concept started in 2004 at the Medication Administration Policy Advisory Subcommittee of the Drugs & Therapeutics Committee in Edmonton & Area Proactive medication safety initiative High-risk, low-cost initiative JCAHO Requirement ISMP Canada Recommendation Now (2009) a ROP for Accreditation Canada 3

4 Which Abbreviations To Prohibit? Only those associated with morbidity & mortality wanted to keep the list small but have big impact IU or U Avoid QD or qd QOD Unit Daily Use Every other day Considered those required by Drug Names Write out drug name JCAHO & recommended by ISMP Canada Trailing Zero No zero after decimal Leading Zero Put zero before decimal 4

5 Getting Started Baseline audit January 2005 Audited all orders received in 1 day from 3 sites totaling over 4000 drug orders Average use of prohibited abbreviations = 22.2% (range 20-23%) or 917 drug orders Highest offender qd or QD instead of daily = 14.3% 5

6 Getting Approval Presented (May 2005) list of prohibited abbreviations, corporate policy, & baseline audit results to: Drugs & Therapeutics Committee Regional Medical Advisory Council Considered a key region-wide patient safety initiative Key discussion point was enforcement versus education Education preferred option 6

7 Approach to Education Determined Education Objectives: Describe rationale for the prohibited abbreviations project List the prohibited abbreviations Indicate the correct documentation that replaces prohibited abbreviations Review examples of medication abbreviations that pose the greatest risk to patient safety. 7

8 Approach to Education Developed Education Materials Poster Chart sticker for plastic bookmark that marks place for daily orders Power Point presentation for in-services and for mounting on webpage with speaker notes Post-It Notes to mark noncompliant orders Website accessible from Quality or Pharmacy web pages Created Tool Kits for every ypatient care unit 8

9 Poster 9

10 Chart Bookmark Sticker Prohibited Abbreviation IU U or u QD or qd QOD or QOD Zero after decimal point (e.g. 1.0mcg) No zero before decimal dose (e.g..5 mg) Correct Use Unit Unit daily every other day 1 mcg Never use zeros after decimal 0.5 mg Always use zeros before decimal Drug name abbreviations Complete spelling of generic drug names For more information: Online: or ask your Clinical Nurse educator, patient care manager or pharmacist. 10

11 Post-It Notes 11

12 Approach to Education Education was Region Wide All programs at all major sites over 80 in-services delivered Physicians, Nurse Practitioners, Nursing & Pharmacists Letter to all physicians and medical residents co-authored by VP Medical Affairs/Dean of Faculty of Medicine & Dentistry Faculty of Medicine & Dentistry website Letter to all nursing colleges Pharmacy Student lecture Changes to PPCO's required ed 12

13 Timing of Audits Implemented October 2005 Post-Implementation Audits: 3 months (December 2005) 8 months (June 2006) 2 years (January 2008) 3 years (January 2009) 13

14 Audit Results Jan 2005 (Baseline) Compliance Audit Dec 2005 Compliance Audit June 2006 Compliance Audit Jan 2008 Compliance Audit Jan 2009 Total # of Orders Audited (n) Total # of Drug Orders With Prohibited Abbreviations Site Variance Medication Orders With Prohibited Abbreviations (%) Overall Medication Orders with Prohibited Abbreviations (%) Most Commonly Used Prohibited Abbreviation QD or qd Drug Name and QD Drug Name and QD Drug Name and QD Drug Name 14

15 Audit Results Overall Medication Orders with Prohibited Abbreviations (%) 25 Prohibited Abbreviations Jan-05 Dec-05 Jun-06 Jan-08 Jan-09 % with 5 0 Aug-04 Feb-05 Sep-05 Mar-06 Oct-06 Apr-07 Nov-07 Jun-08 Dec-08 Jul

16 Audit Results Number of Prohibited Abbreviations and Orders Audited d 8000 ited Number Aud Jan-05 Dec-05 Jun-06 Jan-08 Jan-09 Total # Drug Orders Audited (n) Total # of Drug Orders With Prohibited Abbreviations Number of Prohibited Abbreviations 0 Aug-04 Feb-05 Sep-05 Mar-06 Oct-06 Apr-07 Nov-07 Jun-08 Dec-08 Jul

17 Audits of TPN Orders Baseline (January 2005) Audited 1 week s worth of TPN orders from 3 sites for a total of 212 orders Range of use of prohibited abbreviations 11-56%, mainly due to trailing zero Focused education to dieticians at one regional meeting 3 month audit (December 2005) Audited 1 week s worth of TPN orders from 3 sites for a total of 110 orders Use of prohibited abbreviations essentially eradicated there was only one TPN order that contained QD 17

18 Error Prone Drug Name Abbreviations Of the 296 drug name abbreviations found, 83 (28%) were from ISMP s List of Error Prone Abbreviations Error Prone Drug Name Abbreviations - ISMP ARA A HCI HCTZ MgSO4 T3 TAC Nitro Drip PCA 18

19 Error Prone vs. All Drug Name Abbreviations hibited tions % with Pro Abbrevia ISMP Error Prone Abbreviations All Drug Names

20 Summary of Latest Audit Based on the results of the audit, we had a compliance rate of 92.1% Filtering for just the ISMP s List of Error Prone Drug Name Abbreviations, our overall rate of compliance increases to 95.2% Of the 20 error prone drug name abbreviations identified by ISMP, 60% had a frequency of zero in the charts audited. 20

21 What is being done between audits? Attempt to identify specific individuals or prescriber groups who are non-compliant Share audit results with medical staff, medical residents, nurse practitioners & pharmacists Medical ground rounds Annual residents half-day education session Payroll notifications/reminders Electronic messaging Provincial approach with HQCA 21

22 ROP for Accreditation Canada The organization has identified & implemented a list of abbreviations, symbols, and dose designations that are not to be used in the organization. Tests for compliance Have a list inclusive of ISMP Canada s Do Not Use List Implement the list & apply to all medication-related t d documentation, free text in computer, PPCO's, labels, etc. Educate staff to list Update list & implement as necessary Audit compliance & make changes on identified issues 22

23 Where Do We Fall Short for ROP? Missing 9 abbreviations as per ISMP Canada s Do Not Use List : OS, OD, OU µg CC >, < 23

24 Audit Results for All Do Not Use Abbreviations Dangerous Abbreviations IU U QD QOD Drug Name 71 0 Trailing Zero 119 OS No Leading Zero OD 296 OU D/C 35 CC UG > 40 < 24

25 Next Steps Annual audits Continue education efforts to Undergraduate Medical Students, Medical Residents and Nurse Practitioners Target specific abbreviations Error prone drug names d/c cc MgSO4 25

26 Learnings Education can work just as well or better than enforcement Yields excellent results because of a greater understanding of why this initiative is so important Preserves the relationship between pharmacy and prescriber, and nurse and prescriber Educational benefits take time to realize Constant communication and education are vital Regular audits are crucial 26

27 Prohibited Abbreviations Working Group Pharmacy, Nursing, Quality & Medical Staff Karen Horon - pharmacy Gayle Urquhart - nursing Denise Steele - nursing Shelley Johannsson - nursing Kefah Hayek - quality Carmel Montgomery - quality Nicole Simpson regional nursing affairs Dr. Trevor Theman medical staff insight i early on 27