The pattern of most concern was use of the abbreviation U for units. The use was particularly high on one medical and one surgical unit. Eight medication errors related to the use of U for prescribing insulin had been documented in the previous year. Further investigation into how U was being used found that it was commonly used by both nurses and doctors in documenting care in the patient health record.
The Pharmacy Manager developed a proposal for an abbreviation initiative that would target the use of U instead of units in medication ordering. Although the use of U for units in charting was also recognized as an issue, it was felt that it would be most productive to focus on medication ordering first.
The stated desired outcome of the initiative was that in twelve months the word units rather than U would be used to specify the dosage of appropriate medications in all medication orders. The Pharmacy Manager realized this was an ambitious goal but felt that anything less posed an unacceptable safety risk to patients.
After securing executive support for the initiative, the Pharmacy Manager assigned one of the pharmacists to be the project lead. Using results from the audit of abbreviation use they engaged the medical and nursing staff leaders, and the medical leads for medicine and surgery as key champions. With assistance from the champions, a physician and surgeon were identified to join the project team, as well as nursing managers from the surgery and medicine units, a pharmacy technician, and frontline nurse.
The improvement team decided that a feasible interim aim for the project, that would allow them to test some change strategies before rolling it out to the entire hospital, was: “Increase the use of units in ordering medications to 85 per cent of all applicable orders on the target medical and surgical units within six months.”
The project team decided to collect baseline data from medication orders received by the pharmacy from the target units on five randomly selected days over a two week period:
A simple data collection form was developed with columns for medication name (check off heparin, insulin or other), dose designation used (check off U or units), and prescriber initials.
To analyze the data, the total number of orders for each medication category was tallied for each prescriber, and the proportion of each for which units was used was calculated. The team decided it was important to use positive reinforcement by illustrating how often the desired practice, units, was used. A bar graph was prepared that illustrated by prescriber the proportion of orders for heparin, insulin and other medications for which units was used as the dose designation. Prescriber identity was protected by not including initials on the graph.
The project team determined that the primary change strategy would be education combined with feedback to individual prescribers about their use of units and U. A phased approach to education was proposed beginning with a letter from the chief of medicine and the chief of surgery to their colleagues setting expectations for performance. This would be accompanied by a personalized report for each prescriber showing how their prescribing compares to that of their unnamed colleagues. This would be followed by an inservice education program presented in person and accessible as a podcast through the internal website. Posters were designed for the nursing station to raise awareness of the issue and reinforce key messages from the inservice.
The project team continued with data collection in the last two weeks of every month to assess the impact of the interventions that were tried. The letter to prescribers was followed one month later by the inservice education program and accompanying posters. Each month, feedback was provided to prescribers showing how their use of units in ordering medications compared to their anonymous colleagues, and a graph showing how the proportion of their total orders that used the full word units changed over time (run chart). After three months, a 75 per cent compliance rate with the use of units to order the target medications had been achieved; more than half of the prescribers were consistently using units for all their orders.
After four months, it was noted that three prescribers began to revert to their former practice of consistently using U instead of units. A targeted intervention was designed for this small group which consisted of personal contact by their chief of service to emphasize expectations of performance related to medication ordering and a phone call from the pharmacy to request a correction of any orders in which U was the dose designation. This was successful in changing the ordering practices of this group.
After five months, the use of U began to gradually increase again across the target units. The timeline of the initiative was extended to try some new strategies. It was decided to add to the order form a reminder to avoid using abbreviations. As an interim solution to test this change, a sticky label was affixed to the top of each new order sheet by the unit clerk. After two months, the use of units had climbed to 80 per cent of all applicable orders. However, this was not considered to be sufficient as patients were still at risk of medication errors from this practice. Finally a policy was implemented in which medication was not dispensed until the order was clarified. This reinforced to the pharmacy and nursing staff the importance of not making assumptions about a dose before dispensing or administering a high risk medication like insulin to a patient.
By the end of a nine month project period, 98 per cent of orders for the target medications from the medicine and surgery services used a dose designation of units. The remainder of the orders required follow-up by the pharmacy before the medication was dispensed.
The project team concluded that a ‘no fill’ policy was required to reach 100 per cent compliance with the requirement to use the dose designation units. They also concluded that the education and peer comparison feedback process was a valuable strategy to increase compliance with the expected practice standard. A sequential approach to implementation was chosen for other areas using a similar education and peer feedback process, with priority for implementation given to those areas where use of U was common.
After implementation was completed in each area, the data collection and peer comparison feedback process was repeated two more times at four month intervals as a reminder to prescribers of the expected practice. Key messages from the in-service education program were incorporated into a medication ordering standards online education module that new medical staff were expected to complete. The ‘no fill’ policy was incorporated into existing policies. The order form was changed to include a reminder about the organization’s expected practice regarding the use of abbreviations.
The project team is now assessing whether the initiative needs to be expanded to address the issue of how the abbreviation U is used in charting, or whether there is a need to address other abbreviations that are commonly used in medication ordering.