Abbreviations Toolkit Section 4: Making it Happen Research Effectiveness of Abbreviation Intervention Strategies Education Single education program for residents to decrease the use of nine error-prone abbreviations Significant reduction in abbreviation use from 25.8 per cent to 18.3 per cent. Overall rate remained high suggesting a single intervention was not effective; a system wide approach was recommended. 35 Educational interventions with leadership support Decreased the use of six unsafe abbreviations and dose designations (TIW, µg, trailing zero, U, degree symbol and leading zero) from 19.7 per cent to 3.3 per cent after eight months. 36 Extensive education program for medical students, physicians and nursing targeting abbreviations for insulin units. Reduction in the use of incorrect abbreviations for insulin units from 37.5 per cent to 15.5 per cent. 34 Multifaceted approach Letters, posters and pharmacy issued reminders to prescribers using unapproved abbreviations in medication orders at three acute and continuing care facilities. Use of seven abbreviations (U, IU, qd, od, trailing zeros, lack of leading zeros and ug) declined from 20 per cent to 9 per cent over one year. 75 Use of medication order standards, prescriber education and audit and feedback to decrease prescribing errors in trainee medical staff in ICU. For three groups of trainees, the percentage of prescriptions with prescribing errors fell from 19 to 25 per cent in the pre-training audit to 3 to 7 per cent in the six week post-intervention follow-up. 27
Multifaceted approach Two phase intervention strategy with education and reminders in the first phase and introduction of an unsafe abbreviations policy and further education in the second phase. Prescriptions containing errorprone abbreviations fell from 28.3 per cent to 21.3 per cent after the first phase, and leveled out at 10 per cent after the second phase. 26 Group and one-on-one education sessions, pocket cards and posters used to communicate expectations regarding abbreviation use to emergency room staff. The incidence of error-prone abbreviation use declined from 31.8 to 18.7 per 100 prescriptions in the four-month follow-up period. 38 Evaluated compliance with a medication order writing policy in a health region after education alone and then audits with prescriber feedback. Before intervention 26.3 per cent of medication orders did not comply with the policy. Education alone reduced noncompliance to 24.9 per cent of orders; audit and feedback further reduced noncompliance to 19.1 per cent of orders. 28 Enforcement and leadership Multiple strategies were tried including prescriber feedback letters, one-on-one educational sessions, newsletters, chart notices, information about approved abbreviations on charts, posters, positive reinforcement. Greatest success was achieved with a policy requiring orders with unapproved abbreviations to be rewritten, and with medical staff leaders reinforcing expectations. Education alone was neither effective nor sustainable. In one hospital, improvement occurred only with a rewrite policy requiring for orders with unacceptable Another hospital had success when medical staff leaders followed-up with their colleagues who were using unapproved abbreviations in addition to pharmacist followup on orders with unapproved 11
Enforcement and leadership Collaborative improvement process used with hospital and clinic-based physicians to reduce the use of high-risk Strategies included educational program and printed materials for medical staff, posters, wallet cards. The hospital but not clinics introduced a policy prohibiting use of target abbreviations with feedback to noncompliant physicians. Compliance with abbreviations standards improved from 62.6 per cent to 81.4 per cent in the hospital, but in the community only improved from 69.1 per cent to 72.9 per cent. The difference was attributed to the policy and feedback strategies used in the hospitals. The collaborative process was successful. 88 Education with reminders was followed by implementation of a policy in which prescriptions with error-prone abbreviations were not accepted. Education with reminders was not successful. Enforcement through policy was required. 29 Technology Pre- and post-intervention prescribing error rate in prescribers who converted to a stand-alone e-prescribing system with embedded clinical decision support in an ambulatory care setting. E-prescribing group reduced errors from 42.5 to 6.6 errors per 100 prescriptions compared to no change in the handwritten order group. Use of inappropriate abbreviations decreased from 12.7 per cent to 0.04 per cent and illegibility issues were eliminated. 42 Effectiveness of computerized alerts to reduce the use of error-prone abbreviations in electronic progress notes by physicians. Participants received either no alert, an alert with a forced correction, or an auto-corrected alert. Forced correction of errors resulted in a significantly lower rate of abbreviations in handwritten notes compared to auto-correction. There was no change in knowledge about unapproved 46
Technology Effectiveness of a screening tool for abbreviations within an electronic medical record coupled with continued education and feedback to reduce the use of error-prone The use of error-prone abbreviations decreased by 8 per cent each month for a 37.3 per cent decrease in a six month period. 89 References Note: Taken from the reference list for the Abbreviations Toolkit. 11. Traynor K. Enforcement outdoes education at eliminating unsafe American Journal of Health-Systems Pharmacy. 2004; 61:1314, 1317, 1322. 26. Alshaikh M, Mayet A, Adam M, Ahmed Y, Aljadhey H. Intervention to reduce the use of unsafe abbreviations in a teaching hospital. Saudi Pharmaceutical Journal [Internet]. 2013 [cited 2015 Oct 1]; 21(3):277-80. Available from http://www.sciencedirect.com/science/article/pii/s1319016412000965 27. Thomas, AN, Boxall EM, Laha SK, Day AJ, Grundy D. An educational and audit tool to reduce prescribing errors in intensive care. Quality and Safety in Health Care. 2008; 17:360-363. 28. Raymond CB, Sproll B, Coates J, Woloschuk D. Evaluation of a medication order writing standards policy in a regional health authority. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada [Internet]. 2013 [cited 2015 Oct 1]; 146(5):276-283. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3785189 29. Garbutt J, Milligan P, McNaughton C, Highstein G, Waterman B. Dunagan W. et al. Reducing medication prescribing errors in a teaching hospital. The Joint Commission Journal on Quality and Patient Safety. 2008; 34(9):528-536. 34. Lewis AW, Bolton N, McNulty S. Reducing inappropriate abbreviations and insulin prescribing errors through education. Diabetic Medicine; 27(1):125-126. 35. Burkiewicz J and Hassenplug K. Educational interventions to reduce frequency of use of restricted abbreviations in a community health center. Journal of Pharmacy Technology. 2006; 22:332-335. 36. Abushaiqa M, Zaran F, Bach D. Education interventions to reduce the use of unsafe American Journal of Health-System Pharmacy. 2007; 64:1170-1173.
38. Taylor S, Chu M, Haack L et al. An intervention to reduce the use of error-prone prescribing abbreviations in the emergency department. Journal of Pharmacy Practice and Research. 2007; 37(3):214-216. 42. Kaushal R, Kern L, Barron Y, et al. Electronic prescribing improves medication safety in community-based office practices. Journal of General Internal Medicine. 2010; 25(6):530-536. 46. Myers JS, Gojraty S, Yang W, et al. A randomized-controlled trial of computerized alerts to reduce unapproved medication abbreviation use. Journal of the American Medical Informatics Association [Internet]. 2011 [cited 2015 Oct 1]; 18(1):17-23. Available from: http://jamia.oxfordjournals.org/content/18/1/17 75. Poloway L, Greenall J. Medication safety alerts Taking action on error-prone Canadian Journal of Hospital Pharmacy. 2006; 59(4):206-209. 88. Leonhardt KK, Botticelli J. Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians. Journal of Patient Safety. 2006; 2(3):147-153. 89. Capraro A, Stack A, Harper B et al. Detecting unapproved abbreviations in the electronic medical record. Joint Commission Journal on Quality and Patient Safety. 2012; 38(4): 178-183.