Questions and Answers - Patient Safety is in YOUR Hand! Q1 ...

Questions and Answers - Patient Safety is in YOUR Hand!

Q1: Why is avoiding the use of certain abbreviations important for patient safety?

A1: The Commonwealth of Pennsylvania Patient Safety Authority conducted a review of 103 critical incidents and found that over half of them involved the use of prohibited abbreviations. Many national organizations such as the Institute for Safe Medication Practices (ISMP-Canada), the Accreditation Canada and the Canadian Patient Safety Institute (CPSI), have identified the removal of dangerous abbreviations as a key patient safety initiative. On a provincial level, the Manitoba Institute for Patient Safety (MIPS) in collaboration with the College of Registered Nurses of Manitoba (CRNM), the Winnipeg Regional Health Authority (WRHA) and the Manitoba Pharmaceutical Association (MPhA) has developed a "Do Not Use: Dangerous Abbreviations , Symbols, Dose Designations" card and are advocating its application in all healthcare settings across the province.

Q2: Where do I go for more information on safe medication order writing including the "Do Not Use" card and how I can adopt it into my practice?

A2: The Manitoba Institute for Patient Safety website houses information on this initiative along with a number of tools that may be applied in your workplace (). In addition, an interdisciplinary healthcare educational event regarding this and other patient safety initiatives was hosted by the Manitoba Pharmaceutical Association on May 22nd, 2008. Electronic copies of the presentations are available through the MIPS office.

Q3: Who is the intended target of the "Do Not Use" card, isn't this only a concern for the prescriber?

A3: While it is important for prescribers to be aware of and avoid error-prone abbreviations. Any individual involved in the writing, transcribing and interpreting of medication orders should be aware of the "Do Not Use" Abbreviation List. The abbreviations should be especially avoided on all patient orders (including verbal orders) and medication administration records.

Q4: If orders are entered by a computerized prescriber-order-entry platform, does that eliminate the risk for error prone abbreviations?

A4: Not necessarily, while most computerized order entry systems should not utilize any error prone abbreviations, they could show up at other points in the process such as the medication administration record (if it is manually generated) or the pharmacy-generated product label. Staff should be vigilant about looking for inappropriate abbreviations wherever orders are interpreted or transcribed.

1

Q5: If an abbreviation or symbol is used from the "Do Not Use" card, is it an invalid order?

A5: This may depend on the approach taken in your region and the "buy in" you receive as you implement restrictions on abbreviations. It may be impractical to invalidate all orders that contain one of these abbreviations; especially for the time shortly after the implementation of the list. The purpose of the "Do Not Use" List is to encourage the removal of these abbreviations from regular order writing and order transcription in order to improve order writing and improve patient safety. If any order, whether a banned abbreviation is used or not, appears ambiguous, it should be clarified with whoever wrote the order. If your region or workplace has a specific standard (see Q and A regarding Medication Order Writing Standard) it should be followed.

Q6: What are Medication Order Writing Standards?

A6: Some Health Regions in Manitoba have adopted Medication Order Writing Standards that explicitly state the Policies and Procedures that are to be followed with respect to orders written within the region. To find out if there are Medication Order Writing Standards in your region, contact the individual responsible for Quality Improvement in your region.

Q7: What has been the experience of regions that adopt Medication Order Writing Standards that included a list of prohibited abbreviations, symbols and dose designations?

A7: As is always the case when you try to change an ingrained practice, like the way prescriptions are written, there is likely to be resistance by some in the healthcare team. It is important to keep in mind that this is a patient safety initiative with the end result being a system where medication errors are reduced. In the WRHA and Capital Health Region (Edmonton), follow-up audits were conducted after the implementation of the order writing standards and "Do Not Use" abbreviation lists. They found improvements in general measures of order writing and marked reductions in the use of error-prone abbreviations. In the Capital Health Region they specifically looked at orders for total parenteral nutrition and found a 96% decrease in the use of prohibited abbreviations within 1 year.

2

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download