Unsafe Abbreviations: MultiCare Health System Celeste Derheimer, RN, MBA, CPHQ

1. Unsafe Abbreviations:MultiCare Health SystemCeleste Derheimer, RN, MBA, CPHQ Washington Patient Safety Coalition January 19, 2006 Teleconference

2. MultiCare Health System • Laboratories Northwest • MultiCare HealthWorks • MultiCare Home Services • MultiCare Medical Associates • MultiCare Urgent Care Centers •Covington • Lakewood • Gig Harbor • University Place • Kent • Westgate • Acute 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

3. JCAHOSurveys • 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

4. 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!!

5. Use of Unsafe AbbreviationsResults – Mary Bridge Children’s

6. 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.

7. Use of Unsafe AbbreviationsResults – Tacoma General/Allenmore

8. Unsafe Abbreviation Use by Profession

9. 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)

11. 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.

12. 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

13. 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

14. 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

15. 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”

16. The Results