Hospital consortium standardizes prescription writing for members

Protocols integrate Joint Commission goals

A consortium of hospital systems in the Minneapolis-St. Paul area has implemented a program to standardize protocols for handwritten prescriptions. The effort integrates Joint Commission on Accreditation of Healthcare Organizations goals for 2004 targeting the elimination of dangerous abbreviations.

As of April 1, hospitals that are members of the Safest in America (SIA) consortium no longer accept medication orders that contain unsafe abbreviations (see list). SIA is composed of nine metropolitan hospitals in addition to the Mayo Clinic in Rochester.

SIA was formed several years ago because the hospitals had health care professionals, including physicians and pharmacists, who worked at more than one of the hospital systems, reports Alison Page, MHA, RN, vice president of patient safety at Fairview Health Services in Minneapolis. "[We said], let’s improve processes together with an eye to standardize them so that doctors, nurses, and pharmacists experience the same thing from institution to institution."

The Institute Clinical Systems Improvement in Bloomington manages the collaborative. "They manage the infrastructure of our improvement work," she adds.

SIA introduced one of its patient safety initiatives last year. In September, it adopted a single, metrowide standard for surgical site marking in an effort to reduce incidences of wrong-site surgeries.

SIA then launched its medication error collaborative, led by Mark Thomas, MS, RPh, pharmacy director at Children’s Hospital and Clinics. The collaborative included teams of clinicians and hospital staff who developed common outcome measures. At that time, Thomas said the group would work to standardize protocols and processes related to:

  • the use of high-risk drugs (one or two would be selected to start);
  • the use of medication-ordering abbreviations;
  • the use of pediatric medications frequently associated with dosing errors.

In addition, the group planned to establish a mechanism to use local expertise among participating hospitals to conduct a peer-reviewed assessment of an identified list of practice recommendations at participating hospitals.

Since that time, SIA implemented a standardized dosing concentration or protocol for certain medications used with children. The consortium also has recommended a standardized protocol for prescribing heparin. The next project in medication safety is insulin management, Page says. This project launched about a month ago.

Meeting Joint Commission goals

When addressing safe prescribing practices, the collaborative wanted to standardize across the hospitals which abbreviations and practices would not be allowed, Page notes.

About halfway into the project, the Joint Commission published requirements regarding the elimination of unsafe abbreviations. For example, accredited organizations now must have a minimum list of five dangerous abbreviations, acronyms, and symbols (U for unit; IU for international unit; QD for daily and QOD for every other day; trailing zero; and MS, MSO4, and MgSO4 for morphine sulfate or magnesium sulfate). As of April 1, accredited organizations also must identify and apply at least another three "do not use" abbreviations, acronyms, or symbols. (see list)

The collaborative integrated the Joint Commission requirement with its list and standardized the items across the community, Page explains.

Currently, prescriptions that are not written appropriately are not filled, she reports. An exception is when the patient is put at risk if the medication order is not filled right away. As the Joint Commission says, the safety of the patient always comes first:

"If, in the judgment of the people providing care to the patient (e.g., the registered nurse and pharmacist), the order is clear and complete and the delay to obtain confirmation from the prescriber prior to execution of the order would place the patient at greater risk, then the order should be carried out and the confirmation obtained as soon as possible thereafter."

With other prescriptions, the physician is called regarding the order, and a form correcting the order is filled out. The consortium initially saw "big numbers" of prescriptions that needed to be corrected, Page reports. These numbers, however, now are declining rapidly. The consortium makes a point of stating that it is looking for flaws in the system that create opportunities for error; it does not want to place blame on any one facility or individual.

The hardest abbreviation to make the change has been QD because physicians don’t think the change is necessary, she says. "Getting them to change their habits around QD has been difficult."

Soon all the hospitals will be putting a "hard stop" on incorrect medication orders, not allowing them to be re-verified and changed verbally. "Eventually, [physicians] will have to fix it themselves."

SIA is in the midst of collecting data about the new protocols and hopes to continually measure their effectiveness throughout the year. The data collection will help in other ways as well. Minnesota passed a new system for mandatory reporting of medical errors during the 2003 legislative session. The new law will require public reporting of certain data related to errors within hospitals, including patient death or serious disability associated with a medication error.