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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