Continuing Care Case Example

Chapter 1: Identifying a Local Problem (Section 1: Making the Case)

In preparation for accreditation, the Director of Care of a long term care facility asked the pharmacy service provider to review abbreviation use in all medication orders received over a six week period. Pharmacy staff recorded any abbreviations used that did not comply with the facility’s medication order writing policy.

The pattern of most concern was use of the abbreviation U for units when insulin was ordered. The Director of Care also reviewed medication errors from the past year, focusing on those that involved abbreviations. Four medication incidents related to the use of U for designating a dose of insulin had been documented in the previous year. Two of these involved misinterpretation of a physician order and two involved use of U during transcription – one concerned a verbal order transcribed into the resident’s chart/physician orders and the other occurred when a new insulin dose was transcribed onto the medication administration record by a nurse.

Chapter 2: Establishing an Outcome (Section 1: Making the Case)

Together the Director of Care and the consultant pharmacist developed a proposal for an abbreviation initiative that would target the use of U instead of units in medication ordering and charting of insulin.

The stated desired outcome of the initiative was that in twelve months the word units rather than Uwould be used to specify the insulin dosage in all medication orders and transcriptions of medication orders for insulin. They realized this was an ambitious goal but felt that anything less posed an unacceptable safety risk to patients.

Chapter 3: Forming the Team (Section 2: Engaging the Right People)

After securing executive support for the initiative, the Director of Care assigned her nurse educator to be the project lead. The facility medical advisor and pharmacy manager were engaged as key champions. With assistance from the champions, a nurse manager, frontline care provider at the facility, pharmacist, and family physician were invited to join the team.

Chapter 4: Stating an Aim (Section 3: Planning for Change)

The improvement team recognized that the initiative needed to target both prescribers and transcribers. The team decided that a feasible interim aim for the project that would allow them to test some change strategies was: “Increase the use of units in ordering and transcribing insulin doses to 85 per cent of orders within six months.”

Chapter 5: Selecting Measures (Section 3: Planning for Change)

The project team decided to gather additional information to serve as a baseline.

1. The pharmacy collected information about all insulin prescriptions over a four week period:

• Dose designation used – either U or unit
• Prescriber initials. A separate list of prescriber names corresponding to the initials was created. It was necessary to identify the prescriber during data collection in order to provide feedback to prescribers during the project.
• Orders transcribed from a verbal prescription were designated with TO.
  A simple data collection form was developed with columns for date, dose designation used (check off U or units), prescriber initials, and whether it was a transcribed order.
  To analyze the data, the total number of orders for insulin 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 written insulin orders for which units was used as the dose designation. Prescriber identity was protected by not including initials on the graph. A separate graph was prepared for verbal prescriptions showing the proportion of transcriptions for which units was used as the dose designation.

2. Over the same four week period, the consultant pharmacist reviewed all new and changed insulin orders transcribed at both the facility and the pharmacy. The identity of the transcriber was not collected. A bar graph was prepared that showed the proportion of transcribed verbal orders for insulin at the facility and pharmacy for which units was used as the dose designation.

Chapter 6: Choosing Interventions (Section 3: Planning for Change)

The project team determined that the primary change strategy would be education accompanied by prescriber feedback. The medical advisor sent a letter to all physicians caring for residents of the facility setting expectations for insulin ordering. For prescribers who had ordered insulin during the baseline period, the letter included a bar graph showing how that prescriber’s use of units and Ucompared to that of their anonymous colleagues. Posters were designed for the nursing stations to raise awareness of the issue and reinforce key messages. A 10 minute inservice suitable for presentation at shift change was developed for nursing and pharmacy staff. It highlighted the problems encountered when U is used as the dose designation for insulin and how this had contributed to medication incidents at the site. It also included information on the use of U in transcribed orders. Expectations for using units instead of U in transcribing orders were established.

Chapter 7: Cycles of Change (Section 3: Planning for Change)

The educational intervention took place over a two week period. After that period, the project team resumed data collection on all insulin orders. After each four week period, bar graphs were created showing how the use of units during that period compared to the baseline period. Prescriber feedback was sent out showing each prescriber how their use of units was changing over time compared to that of their anonymous colleagues. Posters were placed in the pharmacy and in staff areas at the facility to show how the use of units by physicians and in transcribed orders was changing over time.

After four months, the nursing and pharmacy staff were consistently using units to transcribe orders for insulin, with a 97 per cent compliance rate. Staff responded quickly to personal requests, usually from their colleagues, to change an order they had transcribed incorrectly. There was a steady increase in the use of units by prescribers, with an overall 75 per cent compliance rate by the end of the fourth month. Compliance ranged from 100 per cent to zero – three prescribers continued to use U to prescribe insulin for all orders. The medical advisor contacted these individuals personally to discuss expectations for ordering insulin. Compliance issues were also noted when new physicians or locums providing vacation relief prescribed insulin. These prescribers were sent a letter from the medical advisor followed by a prescriber feedback letter after four weeks of data collection.

By the end of the six month period the aim of 85 per cent compliance with the insulin ordering policy had been achieved and the ordering practices of recalcitrant physicians had improved. However the project team decided that this was not sufficient because patients were still at risk of medication errors from misinterpreted orders. It was decided to implement a policy in which insulin doses designated with U would not be dispensed until the order was clarified with the prescriber. This reinforced to the staff the importance of not making assumptions about a dose before administering a high risk medication like insulin to a patient.

Data collection continued for another two months at the end of which the compliance rate for prescribers was 98 per cent. Nursing and pharmacy staff consistently continued to use units when transcribing orders for insulin.

Chapter 8: Implementation Strategy (Section 3: Planning for Change)

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. No additional implementation strategy was needed because the practice of all prescribers and those who transcribe orders had been addressed during the test and refine stage.

Chapter 9: Sustaining Change (Section 3: Planning for Change)

After implementation was completed, 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. Transcription of insulin orders was reviewed and reported to staff at the same time. Key messages from the in-service education program were incorporated into a medication ordering standards online education module that new nursing, pharmacy and attending physicians were expected to complete. The ‘no fill’ policy for insulin 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.