Unsafe Abbreviations:MultiCare Health System

Celeste Derheimer, RN, MBA, CPHQ

Washington Patient Safety Coalition

January 19, 2006 Teleconference

MultiCare Health SystemAcute Care & Surgical

Centers– Allenmore Hospital– Mary Bridge Children’s

Hospital & Health Center– Tacoma General Hospital– MultiCare Day Surgery

Centers

MultiCare Clinics• Auburn • Lakewood• Covington • Northshore• East Hill • Spanaway• Gig Harbor • University

Place• Kent • Westgate

Laboratories Northwest MultiCare HealthWorks MultiCare Home

Services MultiCare Medical

Associates MultiCare Urgent Care

Centers• Covington • Lakewood

• Gig Harbor • University

Place• Kent • Westgate

JCAHO Surveys Three surveys in two weeks in

April– Tacoma General/Allenmore– Mary Bridge Home Infusion– Mary Bridge Children's Hospital

Then we had two more in August– Home Health– Hospice

JCAHO Survey Experience

Mary Bridge Children’s Hospital and Mary Bridge Home Infusion Services (April ’05)

Home Health and Hospice (August ’05)– No unsafe abbreviations observed!!

Use of Unsafe AbbreviationsResults – Mary Bridge Children’s

20%

2%

8%

0% 1%

6%

2%

0%

5%

10%

15%

20%

25%

Q4-03 Q1-04 Q2-04 Q3-04 Q4-04 Q1-05 Q2-05

JCAHO Survey Experience Tacoma General/Allenmore Hospitals

(April ’05)– Although the hospital had a list of

abbreviations, acronyms and symbols not to use, this list was not consistently followed throughout the institution.

– Four uses of unacceptable abbreviations (qd, u and MSO4) by four different practitioners (2 physicians, a nurse and a pharmacist) were found on 3 different patient tracers.

55.4%

40.4%

27.5%

17.0%

57.0%

23.5%

13.4%0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Q4-03 Q1-04 Q2-04 Q3-04 Q4-04 Q1-05 Q2-05

Use of Unsafe AbbreviationsResults – Tacoma General/Allenmore

Unsafe Abbreviation Use by Profession

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4-03 Q1-04 Q2-04 Q3-04 Q4-04 Q1-05 Q2-05

RPh

RN

MD

Addressing the RFI

Don't need to revise our policy or develop a new/different list!!– Provide additional

training/education in areas were we know there is need

– Focus on unit-level data collection and "immediate" results feedback (positive as well as improvement opportunities)

Tools and Steps Unsafe Abbreviation (USA) Task

Force met every other week A unit-specific data collection tool

was developed. – Each task force member piloted the

data collection tool over a two-week period.

– The tool was used to collect data concurrently and provide 1:1, just-in-time education.

Tools and Steps Using Rapid Cycle Improvement

concepts, the tool was reviewed and revised until the tool/process were ready for implementation.

Once the tool was ready for implementation, unit staff conducted random audits of three charts/week/unit

Data was submitted to Quality, aggregated and returned to the units where they were displayed and discussed in staff meetings

Tools and Steps

Posters were placed in areas where Medical Staff would see them (Physician Lounges, OR, Medical Records)

Letter from the Medical Officer and article in MedStaff News

Updates at all Medical Staff Meetings and CME offerings

Tools and Steps

As the data started coming in, Quality Management developed Physician Specific Reports.– Display of the percent use of unsafe

abbreviations by abbreviation – A second graph provided a blinded

summary of Percent use of Unsafe Abbreviations by Practitioner

Tools and Steps

Posters were placed in areas where Medical Staff would see them (Physician Lounges, OR, Medical Records)

Update article in MedStaff News with the same information

Emails with the same information and graphs were sent to individual physicians providing them with their “code”

The ResultsPercent Use Unsafe Abbreviations

9.5%

12.5%

3.0%

3.8%

7.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

August September October November December