quality and safety project error-prone abbreviations€¦ · problem abbreviations lead to errors....
TRANSCRIPT
![Page 1: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/1.jpg)
Quality and Safety Project
Error-Prone Abbreviations
![Page 2: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/2.jpg)
Problem
Abbreviations lead to errors. ◦ According to Burke (2009), since January 1995, abbreviation errors have made up 9.5 percent of all sentinel events. Sentinel event= an unexpected event that involves death or serious injury; or the risk of serious injury or death.
![Page 3: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/3.jpg)
Top 3 Errors
SC D/C QHS
![Page 4: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/4.jpg)
SC, sub q, SQ
Intended meaning: Subcutaneous
Misinterpreted as: -SC mistaken for SL
(sublingual) -SQ mistaken as 5 every (the
q has been mistaken as “every”
Ex: a heparin dose ordered “SQ 2 hours before surgery” misunderstood as every 2 hours before surgery
Accepted Use/ Correct use:
Subcutaneous (written out)
Correctly written out: 1) Heparin 5000
units=1mL, injections, subcutaneously, q12hours
2) Lovenox 40mg, subcutaneous, daily
![Page 5: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/5.jpg)
Sub q continued…
Possible outcomes? 1)Wrong route
(sublingually) 2)Excessive dosing
error: too frequent (every x hours)
Normal limits of medication and implied possible patient outcomes: Insulin: administration only through
subcutaneous route, otherwise insulin destroyed in GI tract before it can be used; insulin rendered useless. Pt does not receive drug therapy.
-Possible lethal outcome: hypoglycemic, death
Lovenox: administration only through
subcutaneous route, otherwise Lovenox destroyed in GI tract before it can be used; drug rendered useless. Pt does not receive drug therapy.
-Possible lethal outcome: bleeding complications= local ecchymoses to major hemorrhage
![Page 6: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/6.jpg)
D/C: Discharge versus discontinue
~Medication~ Discontinue a medication or discharge
medications Could cause major underdosing or overdosing
when patient is discharged
~Appliances~ Discontinue a hemovac or discharge with the
hemovac Increased risk of infection if hemovac is
discontinued too early
![Page 7: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/7.jpg)
Altered Outcomes
Discharged with a hemovac or sutures, leaving them open to infection
Pain medication discontinued while patient is still in pain
Patient discharged on a medication that needed close monitoring
![Page 8: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/8.jpg)
QHS
• QHS means … Nightly at bedtime • Misinterpreted as … QHR … every hour • Should be written as …Nightly • Found 39 errors of QHS - #1 error found
![Page 9: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/9.jpg)
QHS
Outcomes… ◦ Patient would receive medication every hour instead of just at night.
Dosage calculation… ◦ Patient could get up to 8X more medication then they
really prescribed
![Page 10: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/10.jpg)
Possible Outcomes - QHS
Disaster… ◦ Patient could get lethal doses
of the medication. Depending on medication it could kill the patient very quickly. Cardiac/ Blood pressure
medications Diuretics Pain medications
Nursing care … ◦ Seem incompetent ◦ Loss of RN License/ criminal
charges ◦ Could kill the patient or
seriously injure the patient ◦ Emotional stress
![Page 11: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/11.jpg)
Summary of Data
05
1015202530354045
QHS SC, SUB Q
QDB D/C CC HS @ U /
ERROR-PRONE ABBREVIATIONS FOUND IN CHARTS
ERROR
![Page 12: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/12.jpg)
Possible System Breakdowns
PHYSICIAN and NURSE - Decreased time so the order is
written quickly with an error-prone abbreviation.
- There is a resistance to change from the way “things have always been done”.
![Page 13: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/13.jpg)
Possible System Breakdowns
UNIT CLERK ◦Transcription. ◦ Illegible writing from physician/nurse.
* Difficult to identify specific individuals who used risky abbreviations due to the large amount found in the computer charting.
![Page 14: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/14.jpg)
Fishbone
![Page 15: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/15.jpg)
Healthcare members to work on problem
Doctors Nurses Unit Clerks Pharmacy MD Supervisors, CEO IT
![Page 16: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/16.jpg)
Location of Errors
• Medication errors were about 50/50 between paper chart and M.A.R (computer)
• Vicious cycle – Doctor’s notes in paper chart…
transcribed to computer… entered into M.A.R
• Measure systems with the most error by… – Checking Doctor’s prescriptions
prior to entering them into computer
– Count the number of errors in M.A.R vs. number in chart and run statistics on results
![Page 17: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/17.jpg)
Plan
Structure (interventions): Education, computer-based training and visual exposure
Process steps: physicians orders, transcription into computer, nurse reading and understanding, patient care!
Outcome: patient satisfaction & safety
![Page 18: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/18.jpg)
Plan For Success
Mandatory in-service education
Ways to implement education (auditory & repetition)
Present data in an organized manner to staff
![Page 19: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/19.jpg)
Plan For Success
Positive reinforcement ◦ raffle tickets, gift cards, etc…
Consequences for not attending in-service education ◦ badge access
![Page 20: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/20.jpg)
Plan for success
Repetition in education (Implementation)
Continuing education
Not dropping the ball
Eventual assimilation
![Page 21: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/21.jpg)
Plan: Computer Based Training (CBTs)= training modules
Every year (annual review), employees must complete CBTs educating them about the dangers of error prone abbreviations.
A post-test is provided to ensure understanding/ competency.
Concept based on: Education
Benefits: *Easy to use interfaces *Modular training, performed at one’s pace *Interactive
![Page 22: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/22.jpg)
Plan: LISTS AND POSTERS
Information boards around unit. ◦ Post lists of error abbreviations and reasons to avoid their use. ◦ Continual reminders in a non-threatening way. ◦ Can work as a team to combat issue.
![Page 23: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/23.jpg)
Don’t Drop the Ball
Write It All
Abbreviations to Avoid: •SC •D/C •QHS •QDB •cc •u
Keep your patient safe!!
Abbreviations can cause:
•Overdose •Uncontrolled pain •Pt injury •DEATH
![Page 24: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/24.jpg)
Plan for success
Possible competition (bar graph)
Group doctors, nurses and unit clerks
(least mistakes)
Positive reinforcement
![Page 25: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/25.jpg)
Do= Proposed Improvement Intervention
Implement education to decrease errors by holding mandatory staff in-services, training modules, and exposure to proposed material (posters,lists, etc…).
![Page 26: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/26.jpg)
Check= Computer Audit
Measure improvement
Computer program
Two column list (employee, error)
Employee asked to visit charge nurse
![Page 27: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/27.jpg)
Check= Computer Audit
Positive reinforcement
Three strike consequences
Reminder’s for actions (bulletin board)
Decrease in abbreviation errors
![Page 28: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/28.jpg)
Act
Training upon hire Keep posters, banners
etc up-to-date Continue in-service quarterly or yearly
seminars Continue positive reward
system Continue consequences if
not implemented
![Page 29: Quality and Safety Project Error-Prone Abbreviations€¦ · Problem Abbreviations lead to errors. According to Burke (2009), since January 1995, abbreviation errors have made up](https://reader036.vdocuments.us/reader036/viewer/2022071011/5fc98bdc2a710d7b62355e9d/html5/thumbnails/29.jpg)
References Burke, Cheryl A., (January 2009).
Sidestepping unsafe abbreviations. Nursing 2009, 21-23.