ED Accreditation Update

Spell it out: Avoid easily misread abbreviations

Be clear and consistent in charts, written orders

It was a tragic story that received national media attention: A 9-month-old died of a morphine overdose administered in a hospital, and the error was traced back to an unseen decimal point in a physician’s order. A prescription for 0.5 mg IV morphine was written ".5 mg," with no zero preceding the decimal point, and was transcribed by a unit secretary as 5 mg, a 10-fold overdose.

This case is a worst-case example of what can happen when abbreviations are not standardized, according to the Joint Commission on Accredit-ation of Healthcare Organizations. In its National Patient Safety Goals, the Joint Commission specifically calls upon accredited organizations to standardize the abbreviations, acronyms, and symbols used throughout the organization and to include in its policies a list of such shorthand symbols that should not be used.

Tift Regional Medical Center in Tifton, GA, put just such a "do-not-use" list in place about eight months ago. The list slowly is showing signs of making a difference, according to April Dukes, RN, head nurse for Tift Regional’s ED.

"When we adopted the list, we posted it, laminated it, made it really colorful," she reports. "We put it in everyone’s hands. We posted it at every nurses’ station in the hospital. We stressed how important it is."

Eliminating misleading or easily misinterpreted abbreviations and dosing instructions is important in terms of patient safety, but also is an important point in a Joint Commission survey. The Joint Commission’s objective for an accredited organization is 100% compliance in clinical documentation, which includes a list of unacceptable acronyms and abbreviations. Through 2004, surveyors will give a finding of compliance if they find fewer than 10% of surveyed charts to include prohibited abbreviations or symbols. An organization must, however, have a plan in place to reach 100% compliance by the end of 2004.

While the Joint Commission presently doesn’t require a set minimum of items to be on the do-not-use list, a list that hospitals frequently look to when drafting their own lists of prohibited abbreviations and shorthand symbols is the one created by the Huntington Valley, PA-based Institute for Safe Medication Practices. (See table.) Also, the Joint Commission is drafting a minimum requirement list, and it is expected to be in place by early 2004.

Some hospitals, such as the University of Kentucky Hospital in Louisville, have standing orders that prescriptions that include certain abbreviations or dose expressions will not be accepted by the hospital pharmacy and must be rewritten before they are executed. Verbal clarification of the abbreviation or dosage is not acceptable.

Richard Croteau, MD, executive director for strategic initiatives for the Joint Commission, says misinterpretation of written orders, or misuse of acronyms and abbreviations, "are particularly dangerous and have resulted in actual patient harm."

According to Dukes, physicians and nurse practitioners slowly are getting used to Tift Regional’s prohibitions on certain shorthand.

"I think they perceive it as time-consuming," Dukes explains. "But the price of a medical error makes it very much worth the time."

Sources

For more information on safe use of abbreviations and acronyms, contact:

  • Richard J. Croteau, MD, Executive Director for Strategic Initiatives, Joint Commission on Accreditation of Healthcare Organizations. One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (401) 295-7147. Fax: (401) 294-8403. E-mail: rcroteau@jcaho.org.
  • April Dukes, RN, Emergency Department, Tift Regional Medical Center, 901 E. 18th St., Tifton, GA 31974. Telephone: (229) 382-7120. E-mail: adukes@tiftregional.com.
  • The Institute for Safe Medication Practices has numerous archived articles and tables on abbreviations, acronyms, symbols, and "sound-alike" medications. Web: www.ismp.org.

Accreditation Q & A

Q: "Are there substantial changes to the performance standard dealing with information privacy and confidentiality (Standard IM 2.10) that my ED should be aware of? What are some common practices that should be avoided?"

A: There are not substantial changes in the standards dealing with information privacy and confidentiality if your facility is already complying with the Health Insurance Portability and Accountability Act (HIPAA) rules previously required, says Paula Swain, RN, MSN, CPHQ, director of clinical and regulatory review for Presbyterian Health Care in Charlotte, NC.

"Issues such as name of patient exposed, listing of patients in triage in a common place, calling and leaving lab or X-ray findings on an answering machine, and cold calling patient phones and discussing follow-up issues with anyone who answers are obvious no-nos," she says.

The Joint Commission created this version of the standards to comply with the intent of the HIPAA regulations, Swain says.

"There likely will be a few questions for the staff to be able to demonstrate that they are in the thick of privacy and confidentiality protection," she explains. "An answer like, We participate in trash can audits,’ would be a sign to the surveyor that they are aware of what needs protection and a monitoring method to ensure the practice is carried out correctly."

An example of items to look for in a trash can audit would be anything with a patient’s name on it, Swain says, including reports, notes, or computer printouts.

(Editor’s note: Submit questions or suggestions for this section to Joy Daughtery Dickinson, Senior Managing Editor. E-mail: joy.dickinson@ahcpub.com.)