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Slide 2 Prescription for Safety: Medication Order Writing & the Do Not Use Abbreviations Slide 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. Slide 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, Hbert P, Hoffman C. The Canadian Patient Safety Dictionary. Ottawa: Royal College of Physicians and Surgeons of Canada; 2003:12. Slide 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. Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 11 Abbreviations and Errors Text Text 2 Slide 12 Text Text 2 Slide 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 Slide 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 Slide 15 An assessment of MKs 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 Slide 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 Slide 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 Slide 18 Slide 19 Slide 20 Slide 21 Public awareness and expectation that all reasonable measures are taken to ensure safety Professional Responsibilities Medical-Legal issues Slide 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 Slide 23