2. Prescription for Safety: Medication Order Writing & the “Do Not Use” Abbreviations

3.  To enhance understanding of the linkages between medication safety and communication.  To ensure that all healthcare professional and associated staff are familiar with the “DO NOT USE: Dangerous Abbreviations and Symbols, Dose Designations” Materials from the Manitoba Institute for Patient Safety.  To review Manitoba cases of communication breakdowns in medication order writing related to dangerous, abbreviations and symbols.  To understand personal responsibilities related to safe medication practices.

4. The reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomes Definition of Patient Safety Davies JM, Hébert P, Hoffman C. The Canadian Patient Safety Dictionary. Ottawa: Royal College of Physicians and Surgeons of Canada; 2003:12.

5. 1999 Institute of Medicine Report (USA)  Medication errors - 106,000 deaths a year average of 300 deaths per day, every day.  Deaths from all major airline crashes in the U.S. average less than 300 annually  Media/Public attention on airline crash vs. med error deaths which are like an airline crash, but every day.

6.  7.5% of patients experienced 1 or more adverse events  36.9% of these patients experienced a highly preventable adverse event  9,250 to 23,750 deaths from adverse events could have been prevented CMAJ 2004

7. 1. Human factors 2. COMMUNICATION 3. Name confusion 4. Labeling 5. Packaging Retrospective analysis of mortalities associated with medication errors. Am J Health-Syst Pharm – Vol 58 Oct 1, 2001

8. 1. Human factors 2. COMMUNICATION 3. Name confusion 4. Labeling 5. Packaging Retrospective analysis of mortalities associated with medication errors. Am J Health-Syst Pharm – Vol 58 Oct 1, 2001

9. Verbal Communication Failure  A nurse in a busy emergency department received a verbal order for digoxin and wrote the order as it was ‘heard’.  The nurse intended to give the higher end of the dosing range as the patient was very unwell.  Fortunately, an error was avoided when it was identified through further communication with other health care providers that the intent of the prescriber was Digoxin 0.125 mg po daily. “Digoxin.1 to 5 mg po daily ” WRHA Example

10. Written Communication Failure  Coumadin 1mg or 10mg? Patient received 10mg when 1mg was intended.  Risperidone 1.0mg or 10mg? The intent was 1mg.  Intended dose of “0.4mg” of vincristine but was interpreted as 4mg from medication order. Should be written as 0.4mg. WRHA and FDA Examples

11. Abbreviations and Errors  Text ◦ Text 2

12.  Text ◦ Text 2

13.  MK is a 67 year old male with a 10 year history of type 2 diabetes  He has recently been started on insulin and has been reasonably well controlled  He seen in the ER and diagnosed with pneumonia. He is started on IV levofloxacin and transferred to a medical ward where the following order is written: Case Consideration

14.  Entered in the pharmacy system with a frequency of once daily  Nursing Medication Administration Record reflects a frequency of QID (four times daily). 80% of errors occurred when the prescription was written but 20% occurred afterwards (ex. transcription) Joint Commission Journal of Quality and Safety 2007

15.  An assessment of MK’s blood sugar shows a fasting blood sugar of 27  The physician on rounds suggests an additional dose of regular insulin and writes the following order Case Consideration

16.  The prescription for 6 units of regular insulin was misinterpreted as “60”  60 units of regular insulin was given  MK became hypoglycemic and unresponsive but made a full recover after the administration of IV glucose  Recommendation: Write out “units” to avoid confusion

17.  Patient Safety is in YOUR Hand!  Posters to address specific abbreviations  DO NOT USE: Dangerous Abbreviations, Symbols and Dose Designations  Adapted from Institute for Safe Medications Practices (ISMP) listing  Endorsed by Colleges, WRHA and is in use in some form in all RHAs in Manitoba Posters are Copyright of the Winnipeg Region Health Authority

21.  Public awareness and expectation that all reasonable measures are taken to ensure safety  Professional Responsibilities  Medical-Legal issues

22. Why Else?  Accreditation Canada Required Organizational Practice 2009  The organization has identified and implemented a list of abbreviations, symbols, and dose designations that are not to be used in the organization.  Order Writing Standards  Most RHAs have already adopted Order Writing Standards that address the issue of abbreviations and other order writing practices

23. “When anyone asks me how I can best describe my experience in nearly forty years at sea, I merely say, uneventful. Of course there have been winter gales, and storms and fog and the like. But in all my experience, I have never been in any accident... or any sort worth speaking about. I have seen but one vessel in distress in all my years at sea. I never saw a wreck and never have been wrecked nor was I ever in any predicament that threatened to end in disaster of any sort." Edward J. Smith, 1907 Captain, RMS Titanic, 1912

24.  Set a personal example  Consider standard orders, care maps and guidelines  Medication Labels and Software  Advertising  Journal Articles  Trade Journals

25. Recommendations for Healthcare Professionals  Avoid writing ambiguous orders with Do Not Use abbreviations in written orders  Safety First – seek clarification of any order that is unclear or ambiguous  Work with computer software vendors to make changes in electronic order entry programs.  Consider Computerized Physician Order Entry (CPOE) Systems that avoid both handwriting challenges and the use of unclear abbreviations (ex. CancerCare MB)  Ensure all staff have access to the MIPS “Do Not Use” Documents  Include MIPS “Do Not Use” information in training of healthcare employees and students

26. Nurses Pharmacists Physicians Medication Safety Team Approach Management Support Staff

27.  Educational Outreach/Awareness  Local Champions  Mandatory Education  Audit and Feedback  Challenges  Habits of order writing are deeply ingrained  Perceived lack of importance Carrot and/or Stick

28.  “Enforcement outdoes education at eliminating unsafe abbreviations”  AJHP 2004; 61: 1314-1315.  Anecdotal discussion with 3 major healthcare facilities in the United States  All conducted extensive educational outreach  None showed any marked improvement in abbreviation use  Two of the facilities implemented strategies that lead to improvements in order writing …and/or Stick

29.  Strategy #1  All medication orders with unacceptable abbreviations were considered to be invalid and required that the prescribers rewrite the orders  Strategy #2  Developed a physician-owned process. They had to manage it, and they had to enforce it …and/or Stick

30. MIPS  http://www.mbips.ca/wp/initiatives/patient-safety-is-in-your-hand/ http://www.mbips.ca/wp/initiatives/patient-safety-is-in-your-hand/ FDA  http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm ISMP  http://www.ismp.org/tools/abbreviations http://www.ismp.org/tools/abbreviations Health Canada  http://www.hc-sc.gc.ca/dhp-mps/medeff/advers-react-neg/index-eng.php Web Resources

31.  Post Test – Review Your Knowledge of “Do Not Use” Abbreviations  http://www.mbips.ca/wp/hidden-link/exam-test-page/ http://www.mbips.ca/wp/hidden-link/exam-test-page/  Accreditation form will be emailed upon completion of post test  Pharmacists: Accredited by MPhA #30196M  Nurses: Participation in this self-directed learning activity may fulfill the requirements of the College of Registered Nurses of Manitoba Continuing Competence Program.  Please retain post test as record of self directed learning Professional Develoment/CEU