Sharpen your pencils: Nurses writing more as abbreviations disappear

No more d/c, u, Q.D., or Q.O.D.’ on Joint Commission’s list

Old habits are hard to break. But the Joint Commission on Accreditation of Healthcare Organizations is asking home health nurses to break some habits they’ve had since nursing school. National Patient Safety Goal #2 requires health care organizations to standardize abbreviations, acronyms, and symbols and to develop a list of do-not-use abbreviations.

The list includes abbreviations that most commonly are misinterpreted and likely to cause an adverse outcome. All Joint Commission-accredited organizations were required to have a minimum list of do-not-use abbreviations in place by Jan. 1 of this year and have until April 1 to add at least three other abbreviations pertinent to the organization to the list. (See list of abbreviations.)

"Home health agencies are struggling with this requirement more than other areas of health care for several reasons," says Patricia W. Tulloch, RN, BSN, MSN, senior consultant with RBC Limited, a health care management consulting firm in Staatsburg, NY. "This requirement significantly affects organizations that have not automated their documentation methods. Our studies have shown that between 40% and 60% of home health agencies still have staff members handwriting patient-specific information such as assessments, chart entries, and patient instructions," she says.

"We also have nurses with an average age of 48, which means they have been using these abbreviations for [more than] 20 years," Tulloch adds. "Use of some of the abbreviations, such as d/c for discharge, is an ingrained behavior for many of these nurses," she explains. "Add the extra amount of writing required when abbreviations can no longer be used and you’ve got a real challenge to change the behavior."

There are five items on the minimum required list developed by Joint Commission and seven items on the list of additional abbreviations to consider when expanding the do-not-use list. "When we reviewed the additional list, we realized that they were all abbreviations we regularly use, so we included all of them to come up with 12 items on our do-not-use list," says Sue Gibson, RN, director of Midwest Home Health Services in Del City, OK.

The short length of the list was a positive aspect that Gibson used to introduce the new requirement to nurses. "Previously, we had a huge list of approved abbreviations that nurses had to flip through, so we promoted the new list as only 12 abbreviations that you have to remember not to use," she continues.

Be sure to explain the why of the change, Tulloch recommends. "If nurses hear that we have 100,000 deaths each year in this country due to medication errors as a result of illegible writing, they will immediately understand the importance of this change," she says.

Mandatory inservices to explain the list and patient safety factors involved were presented before implementing the do-not-use list in January, but Gibson’s nurses also received a laminated card with all 12 abbreviations to place on their clipboards so that information would be available.

A tool, such as a laminated card, is essential to making sure nurses will comply with the requirement, Tulloch points out. "There must be a visual reminder such as the card, signs on the bulletin board, and a flyer to hang above the desk if we are to help nurses remember not to use these abbreviations," she says. Don’t rely upon one inservice to get the message across, either, Tulloch suggests. "You must plan to reinforce this lesson in staff meetings, patient conferences, chart reviews, and other inservices," she says.

Review looks for compliance

Monitoring adherence to this policy also is important, especially in these first few months, Tulloch says. "Setting a goal of 100% compliance is unrealistic, so I recommend that an agency start with a goal of 80% compliance and then improve from that point," she says. "Unfortunately, the agencies of which I’m aware have not reached 80% yet," she adds. "We always review 100% of our records every month during our billing audits," points out Gibson. "We added the do-not-use abbreviations as another item on the audit tool used by our staff," she says. As staff begin to audit the first month’s records, they will note who is and isn’t using the correction terminology, and the agency will schedule one-on-one retraining, she adds.

Gibson also has asked the nurses reviewing the records to look for any other commonly used abbreviations that might be misinterpreted. "We are going to use our findings from the first several months of audits to identify any other abbreviations that should be included on the list," she explains.

"It is important not to make the chart review process result in any punitive actions against nurses," Tulloch explains. "The ideal review would involve a nurse reviewing a chart, noticing an abbreviation that should not be used, then directly contacting the nurse to remind her of the new requirement."

"If the audit and follow-up is peer to peer rather than peer to supervisor to nurse, the process is less threatening," she says. The contact between peers to report an error also should occur immediately so that the nurse who made the error can correct the records and stop making the error as he or she goes forward, she adds.

CHAP standards address terminology

Organizations accredited by the Community Health Accreditation Program (CHAP) in New York City do have to ensure that patient records and instructions are legible, accurate, and easily understood, but they don’t have to develop a specific list of abbreviations to avoid, says Harriett Olson, RN, MNEd, vice president of CHAP. CHAP standards address these issues in several sections of both their core standards that apply to all organizations and in sections that are applicable to home health, she says. "Our surveyors will look for a policy that designates acceptable medical terminology and abbreviations, but we do not issue a list that we require be used," Olson continues. "We describe the outcome, such as a process to ensure accurate, legible, records, and we let the home health agency staff determine the best way to reach the outcome for their agency," she adds.

When evaluating the abbreviations you plan to add to your do-not-use list, or even your acceptable abbreviations’ list, be sure to coordinate your list with the hospital with which you’re affiliated, or the hospitals from which you get many of your patients, Gibson suggests. "It’s common for many home health patients to go from home care into the hospital and back to home. If you make sure you are all documenting in the same manner, the communication between different providers improves, and we ensure quality, safe patient care," she explains.

[Editor’s note: For more information about the Joint Commission requirements, go to www.jcaho.org and click on National Patient Safety Goals in the "Top Spots" section. The web site contains a list of frequently asked questions about the do-not-use abbreviation list and other patient safety goals-related issues. The Joint Commission also recommends that organizations review a list of dangerous abbreviations relating to medication use that the Institute for Safe Medication Practices has published. The list is available at www.ismp.org.]

For more information about the abbreviations in home health, contact:

Patricia W. Tulloch, RN, BSN, MSN, Senior Consultant, RBC Limited, 48 W. Pine Road, Staatsburg, NY 12580. Phone: (849) 889-8128. Fax: (849) 889-4147. E-mail: ptullo42@aol.com. Web: www.rbclimited.com.

Sue Gibson, RN, Director, Midwest Home Health Services, 3921 S.E. 29th, Del City, OK 73115. Phone: (405) 677-7911. E-mail: sue.Gibson@mrmc.hma-corp.com.

Harriett Olson, RN, MNEd, Vice President, Community Health Accreditation Program, 39 Broadway, Suite 710, New York, NY 10006. Phone: (800) 656-9656 or (212) 480-8828. Fax: (212) 480-8832. E-mail: hholson@chapinc.org. Web: www.chapinc.org.