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August 14, 2018
ISMP Canada's Updated "Do Not Use" Abbreviation List
ISMP Canada recently updated its “Do Not Use” abbreviation list after doing an analysis of use of abbreviations in healthcare settings (ISMP Canada 2018). We like the basic tenet they use about abbreviations: “…abbreviations, as well as symbols and dose designations, are only helpful when their intended meaning is fully understood by all persons who will be deciphering the information and when there is no potential for misinterpretation.” ISMP Canada also stresses that inappropriate use of abbreviations can be particularly hazardous at transitions of care (ISMP Canada 2017).
The report particularly highlights problematic use of route designations such as SL, SQ, and SC, and use of the abbreviation “d” to represent days or doses, and use of the ampersand symbol (&) to denote the word “and”.
SL (intended to mean sublingual), SQ (intended to mean subcutaneous), and SC (also intended to mean subcutaneous) can easily be confused with each other. In addition, “SQ” is sometimes misinterpreted as a “5 every”.
The abbreviation “d” can be interpreted as either days or doses. An example given was the order “Lactulose 15 mL po bid x 2d”. That order was intended to mean “for a duration of 2 doses” but was mistaken as “for a duration of 2 days”.
They also note some abbreviations that we, quite frankly, have not seen used. These include use of fractions meant to convey information about duration or frequency. Examples given are #/24, #/7, #/52 (denoting numbers per 24 hours, 7 days, and 52 weeks, respectively). Another example was a direction for tapering a corticosteroid written as “2/7” and then “1/7”. The intended meaning was that the prescribed dose be given “for2 days” and then “for 1 day”, but the instructions were interpreted to mean treatment “for 2 weeks” and then “for 1 week”, resulting in the patient receiving a longer duration of therapy than was intended and experienced adverse effects for which admission to hospital was required.
There is some good news, however, about fewer dangerous abbreviations with the electronic medical record. The current ISMP Canada bulletin notes that a recent Canadian hospital audit found the rates of dangerous abbreviation use on electronic medication orders was significantly less than on paper orders (0.4% vs. 24.1%, respectively). That is reassuring because during one quality improvement implementation we found numerous dangerous abbreviations in order entry screens and standardized order sets and some third party vendor modules in an EHR (see our July 14, 2009 Patient Safety Tip of the Week “Is Your “Do Not Use” Abbreviations List Adequate?”). Dangerous abbreviations also have a nasty habit of showing up in texted information and are one of our many arguments that orders should never be texted.
The ISMP Canada list (ISMP Canada 2018b) and the even more comprehensive ISMP (US) list (ISMP 2017) are considerably longer than Joint Commission’s list of dangerous abbreviations. In that July 14, 2009 Patient Safety Tip of the Week “Is Your “Do Not Use” Abbreviations List Adequate?”) we discussed that many hospitals only adhere to the shorter Joint Commission “Do Not Use” abbreviation list. In reviewing a hospital’s “Do Not Use” abbreviation list for potential expansion, we found about 4% of total orders had an abbreviation that appears on the ISMP list. However, about one in every seven verbal or telephone orders contained such an abbreviation.
We take heart that the detrimental effect of dangerous abbreviations has likely been mitigated somewhat as we’ve transitioned from handwritten orders to electronically formatted orders. In fact, some of the old ISMP samples of dangerous handwritten abbreviations seem anachronistic when we show them in presentations. But they’ve been replaced by the new kid on the block: texting. In our several columns (listed below) about the dangers of texting orders, we cited use of dangerous abbreviations as one example. In our January 30, 2018 Patient Safety Tip of the Week “Texting Errors Revealed” we noted common texting abbreviations are a threat. We’ve spoken before about the example of a texted “2day” (meaning “today”) getting misinterpreted as “two daily” (ISMP 2009). ISMP provided some other examples of errors related to texted abbreviations last summer (ISMP 2017b) and the latest ISMP survey (ISMP 2017a) uncovered a new one: the text abbreviation “BTW” (meaning “by the way”) was misinterpreted as meaning “twice daily”. And, while we were happy The Joint Commission saw the light and did not reverse its ban on texting orders, the above mentioned ISMP survey notes that the practice probably continues to exist to some degree despite hospital policies banning it.
We recommend healthcare organizations use the ISMP (US) list and perform due diligence in purging such abbreviations that might be buried in their EHR’s in order sets (particularly old ones or “personalized” ones if you allow them) or in third party vendor software modules. Every organization also needs to periodically audit records to see how often dangerous abbreviations continue to be used. You may be surprised at what you find. We also suggest you look at the recommendations in our December 22, 2015 Patient Safety Tip of the Week “The Alberta Abbreviation Safety Toolkit”.
Some of our previous columns on the impact of abbreviations in healthcare:
March 12, 2007 “10x Overdoses”
June 12, 2007 “Medication-Related Issues in Ambulatory Surgery”
September 2007 “The Impact of Abbreviations on Patient Safety”
July 14, 2009 “Is Your “Do Not Use” Abbreviations List Adequate?”
April 2015 “Pediatric Dosing Unit Recommendations”
December 22, 2015 “The Alberta Abbreviation Safety Toolkit”
See our other Patient Safety Tip of the Week columns dealing with texting:
References:
ISMP Canada. Rearming the “Do Not Use: Dangerous Abbreviations, Symbols
and Dose Designations” List. ISMP Canada Safety Bulletin 2018; 18(4): May 30, 2018
https://www.ismp-canada.org/download/safetyBulletins/2018/ISMPCSB2018-05-DoNotUseList.pdf
ISMP Canada’s “Do Not Use Dangerous Abbreviations, Symbols and Dose Designations” list. Original 2006, reaffirmed 2018.
https://www.ismp-canada.org/download/ISMPC_List_of_Dangerous_Abbreviations.pdf
ISMP Canada. Errors Associated with Hospital Discharge Prescriptions: A Multi-Incident Analysis. ISMP Canada Safety Bulletin 2017; 17(1): 1-5 January 31, 2017
ISMP (Institute for Safe Medication Practices). List of Error-Prone Abbreviations. October 2017
https://www.ismp.org/recommendations/error-prone-abbreviations-list
ISMP (Institute for Safe Medication Practices). Safety Brief: “2day” gets “86ed.” ISMP Medication Safety Alert! Acute Care Edition 2009; February 26, 2009
https://www.ismp.org/newsletters/acutecare/archives/Feb09.asp
ISMP (Institute for Safe Medication Practices). ISMP survey shows provider text messaging often runs afoul of patient safety. ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017
ISMP (Institute for Safe Medication Practices). The texting debate: Beneficial means of communication or safety and security risk? ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017
Print “ISMP Canada’s Updated “Do Not Use” Abbreviation List”
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August 2018
The move in recent years toward more restrictive transfusion policies and practices has been fueled by increased recognition of untoward side effects of transfusions and controlled clinical trials demonstrating as good or better outcomes with the more restrictive practices in most cases (see the list of our prior columns at the end of today’s column).
Now, an additional risk associated with transfusion has been identified: venous thromboembolism. Goel and colleagues (Goel 2018) analyzed data from the American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database, They found that perioperative RBC transfusion was associated with higher odds of venous thromboembolism (adjusted odds ratio 2.1), deep venous thrombosis (aOR 2.2), and pulmonary embolism (aOR 1.9), independent of various putative risk factors.
Moreover, they found a significant dose-response effect, with increased odds of VTE as the number of intraoperative and/or postoperative RBC transfusion events increased. The adjusted odds ratios were 2.1 for one event, 3.1 for 2 events, and 4.5 for 3 or more events compared to no intraoperative or postoperative RBC transfusion.
And the association between any perioperative RBC transfusion and postoperative VTE was statistically significant across all surgical subspecialties.
The Goel article goes on to discuss the putative mechanisms by which RBC transfusions might increase the risk of venous thromboembolism.
So the new study provides even more evidence to support restrictive transfusion practices in most cases. You’ll recall the AABB (American Association of Blood Banks) updated its guidelines in 2016 (see our November 2016 What's New in the Patient Safety World column “AABB Updates Transfusion Guidelines Again”) and recommended two tiers of hemoglobin level transfusion triggers (Carson 2016):
But even the recommendation for orthopedic surgery has been challenged. Researchers at Johns Hopkins Bayview Medical Center looked at outcomes in orthopedic surgery patients before and after implementation of a blood management program (Gupta 2017). The program consisted of provider education, tranexamic acid, a new surgical blood order schedule, electronic best practice advisories, a “Why Give 2 When 1 Will Do?” campaign advocating single unit RBC transfusions, and audits with provider feedback for guideline compliance. They found, after implementation of the new program, a 38% decrease in percent of patients transfused, and a 25% decrease in mean RBC units per patient. Median length of stay was one day shorter in the post blood-management group with a statistically significant decrease in 30-day readmission rate and no difference in adverse outcomes. (Note that we discussed the Hopkins program (Sadana 2017) in our December 2017 What's New in the Patient Safety World column “Study Confirms Safety of Restrictive Transfusion Policy”.)
Increasing evidence suggests that more restrictive transfusion practices improve patient safety and outcomes and can lead to considerable financial savings, not only from reduced blood product costs but also from the savings seen with fewer complications, shorter lengths of stay, etc.
Prior columns on potential detrimental effects related to red blood cell transfusions:
References:
Goel R, Patel EU, Cushing MM, et al. Association of Perioperative Red Blood Cell Transfusions with Venous Thromboembolism in a North American Registry. JAMA Surgery 2018; Published online June 13, 2018
Gupta PB, Scher LJ, Yang WW, et al. Impact of a Patient Blood Management Program on Blood Utilization and Clinical Outcomes in Orthopedic Surgery. ANESTHESIOLOGY 2017 Abstract A3101.
http://asaabstracts.com/strands/asaabstracts/abstract.htm?year=2017&index=15&absnum=4722
Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines from the AABB. Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016; Published online October 12, 2016
http://jamanetwork.com/journals/jama/article-abstract/2569055
Sadana D, Pratzer A, Scher LJ, et al. Promoting High-Value Practice by Reducing Unnecessary Transfusions with a Patient Blood Management Program. JAMA Intern Med 2017; Published online November 20, 2017
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2663855
Print “August 2018 Thromboembolism: Another Downside of Transfusions”
We’ve done numerous columns on the impact of fatigue on medical errors. A recent study published in the Mayo Clinic Proceedings (Tawfik 2018) showed that physicians reporting excessive fatigue were almost 40% more likely to have reported a major medical error in the prior 3 months. But, more surprisingly, the study showed that physicians reporting symptoms of burnout were more than twice as likely to have reported a major medical error in the prior 3 months.
The study was based upon physicians in the American Medical Association Physician Masterfile invited to respond to an anonymous survey. The survey was completed by 19% of those who opened the request for participation. Note that the term “burnout” was not used in the survey. Rather, questions included symptoms commonly related to burnout.
54.3% of respondents reported symptoms of burnout, 32.8% reported excessive fatigue, and 6.5% reported recent suicidal ideation. One other factor assessed was a poor or failing patient safety grade in their primary work area and this was reported by 3.9% of respondents. Overall, 10.5% of respondents reported making a major medical error in the prior 3 months. Error in judgment (39%), diagnoses (20%), and technical mistakes (13%) were the most commonly reported errors.
Physicians reporting errors were more likely to have symptoms of burnout (77.6% vs 51.5%;), fatigue (46.6% vs 31.2%), and recent suicidal ideation (12.7% vs 5.8%).
In multivariate modeling, odds ratios (OR) for association with errors were 2.22 for burnout, and 1.38 for excessive fatigue.
As you’d expect, errors were more likely to be reported as the safety grade for their primary work unit worsened. For safety grades B, C, D, and F the respective odds ratios for errors were 1.70, 1.92, 3.12, and 4.37 compared to safety grade A. In a press release about the study (White 2018), co-author Tait Shanafelt said, “This indicates both the burnout level as well as work unit safety characteristics are independently related to the risk of errors.” Lead author Danial Tawfik noted the study also showed that rates of medical errors actually tripled in medical work units, even those ranked as extremely safe, if physicians working on that unit had high levels of burnout. He felt this indicates that burnout may be an even a bigger cause of medical error than a poor safety environment.
As with any study based on responses to a survey, there may well be some degree of selection bias and the results show an association but not necessarily causality. But, while there may be some inaccuracy in the actual statistics, we believe the overall message of the study: burnout is a real problem and it contributes to medical errors and untoward patient outcomes.
We, thus, need better ways to recognize physician burnout and interventions to offer support when we recognize it. Other industries have recognized job burnout and developed approaches to address it. We need to borrow from those industries and apply their approaches to healthcare. An excellent review on physician burnout also recently appeared in the Mayo Clinic Proceedings (Olson 2017).
Also of interest is another recent study that showed physician burnout symptoms were fewer in small independent primary care practices (Blechter 2018). Over 70% of those physicians were solo practitioners so the authors propose one explanation could be the autonomy (ie, control of work environment) associated with owning one's own practice as opposed to working in an integrated health system or Federally Qualified Health Center where providers are subject to greater administrative regulations. They also found that higher “adaptive reserve” scores were associated with lower levels of burnout. They suggest that interventions to reduce burnout in primary care practices should focus on strengthening factors that support organizational capacity for change (ie, strong communication, leadership supports, innovation).
References:
Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic Proceedings 2018; Published online: July 9, 2018
https://www.mayoclinicproceedings.org/article/S0025-6196(18)30372-0/fulltext
White T. Medical errors may stem more from physician burnout than unsafe health care settings. Stanford Medicine Press Release. July 8, 2018
Olson KD. Physician Burnout—A Leading Indicator of Health System Performance? Mayo Clinic Procedings 2017; 92(11): 1608-1611
https://www.mayoclinicproceedings.org/article/S0025-6196(17)30690-0/fulltext
Blechter B, Jiang N, Cleland C, et al. Correlates of Burnout in Small Independent Primary Care Practices in an Urban Setting. J Am Board Fam Med 2018; 31(4): 529-536
http://www.jabfm.org/content/31/4/529.full
Print “August 2018 Burnout and Medical Errors”
Trigger tools have provided a good way to identify adverse events in hospitalized patients and in other healthcare settings (see our prior columns on trigger tools listed below). Most of the early work on trigger tools was done in adult patients but Stockwell et al. (Stockwell 2015) developed and tested a trigger tool that would identify the most common causes of harm in pediatric inpatient environments. Expanding upon that, the safety surveillance tool GAPPS (Global Assessment of Pediatric Patient Safety) has been validated and now studied in multiple children’s hospitals.
A new study shows that adverse event (AE) rates remain high in hospitalized pediatric patients and have not substantially improved over time (Stockwell 2018). Researchers used the GAPPS tool to measure temporal trends in AE rates among hospitalized children from 2007 to 2012. They randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals.
Among 3790 records reviewed, they found 414 AEs (19.1 AEs per 1000 patient days) and 210 preventable AEs (9.5 AEs per 1000 patient days). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 vs 5.1 AEs per 1000 patient days). The most frequently identified AE’s were hospital-acquired infections, intravenous line complications, gastrointestinal events, respiratory-related events, and “other”. As we’d expect, chronically ill children had higher AE rates than patients without chronic conditions (33.9 vs 14.0 AEs per 1000 patient days). They found that neither teaching nor nonteaching hospitals experienced significant variations in AE rate over the time of the study.
In terms of severity, 1.2% of AEs resulted in permanent harm, 10.1% were potentially life-threatening, 0.7% were fatal or contributed to a patient's death. Perhaps most striking is that 50.7% were considered potentially preventable.
In the accompanying editorial, Quinonez and Schroeder (Quinonez 2018) noted some prior studies had suggested AE rates were decreasing but that the GAPPS tool is better at identifying AE’s. But they also note that GAPPS may miss some harms, such as those related to the “diagnostic cascade” that results from overtesting.
Though the analysis did not look at trends after 2012, the findings suggest that adverse events in pediatric patients remain at high levels and that many are potentially preventable. Use of trigger tools like GAPPS can help with identification of such adverse events and help hospitals and health systems identify areas in need of improvement.
Some of our prior columns on trigger tool methodology:
References:
Stockwell DC, Bisarya H, Classen DC, et al. A Trigger Tool to Detect Harm in Pediatric Inpatient Settings. Pediatrics 2015; Published online ahead of print May 18, 2015
http://pediatrics.aappublications.org/content/early/2015/05/12/peds.2014-2152
Stockwell DC, Landrigan CP, ToomeySL, et al. for the GAPPS Study Group
Adverse Events in Hospitalized Pediatric Patients. Pediatrics Jul 2018, e20173360
http://pediatrics.aappublications.org/content/early/2018/07/11/peds.2017-3360
Quinonez RA, Schroeder AR. “GAPPS” in Patient Safety. Pediatrics Jul 2018, e20180954
Print “August 2018 Pediatric Adverse Events”
IHI (Institute for Healthcare Improvement) just published an excellent report/monograph “No Place Like Home: Advancing the Safety of Care in the Home” (IHI 2018). It identifies some of the unique issues that apply to care in the home setting. Much is based on a previous IHI report “Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities” (Carpenter 2017).
They identify the following factors that make safe care in the home especially challenging:
They identify risks specific to care in the home and the potential harms associated with those risks, which often have underlying causes that are interrelated:
The report provides recommendations, strategies, and tools for realizing five guiding principles:
We encourage you to go to the IHI website and download the full report(s). As usual, IHI has done an excellent job of summarizing some of the challenges in yet another healthcare setting.
We also hope you’ll go back to our August 13, 2013 Patient Safety Tip of the Week “Adverse Events in Home Care” that summarized the findings of several excellent Canadian studies on patient safety issues in the home setting.
Some of our prior columns on patient safety issues in the home:
References:
IHI (Institute for Healthcare Improvement). No Place Like Home: Advancing the Safety of Care in the Home. IHI 2018
Carpenter D, Famolaro T, Hassell S, et al. Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities. Cambridge, Massachusetts: Institute for Healthcare Improvement; August 2017
http://www.ihi.org/resources/Pages/Publications/Patient-Safety-in-the-Home.aspx
Print “August 2018 IHI on Safety of Care in the Home”
Print “August 2018 What's New in the Patient Safety World (full column)”
Print “August 2018 Thromboembolism: Another Downside of Transfusions”
Print “August 2018 Burnout and Medical Errors”
Print “August 2018 Pediatric Adverse Events”
Print “August 2018 IHI on Safety of Care in the Home”
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Grantham, NH 03753
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