Section 4: Intervention Strategies
A combination of strategies is required to change a complex behaviour like abbreviation use.
Strategies and the Hierarchy of Change
“Making patients safe requires ongoing efforts to improve practices, training, information technology, and culture.”30
Local interventions to reduce abbreviation use typically involve a combination of policies and guidelines, education, reminders, measurement with feedback, standardization of orders, and information technology support. There is evidence to show a multi-pronged approach can be effective. Enforcement is an additional strategy that organizations often turn to when faced with disappointing outcomes.11,26-29 Leadership is an essential component of all strategies to address safety issues.5
Not all change strategies are equally effective as illustrated by the hierarchy of effectiveness presented below.
TABLE 1. HIERARCHY OF EFFECTIVENESS FOR ERROR REDUCTION STRATEGIES31,32
|SYSTEM BASED||Forcing functions (e.g., orders with error-prone abbreviations not accepted)||High Leverage (more effective)|
|Computerization (e.g., electronic health records, computerized prescriber order entry, alerts/warnings)|
|Standardization of orders (e.g., protocols, clinical order sets)|
|PERSON BASED||Audit and feedback (general, personalized)||Low Leverage (less effective)|
|Reminders (e.g., posters, stickers on charts)|
|Policies/guidelines (e.g., medication order writing standards)|
|Education (e.g., presentations, e-learning modules)|
Abbreviation Initiative Strategies
Intervention strategies, presented in the order from most to least effective according to the hierarchy of effectiveness, are described below. These strategies can be adapted for any care environment – acute care, continuing care, and primary care. A summary of the research related to interventions and some resources related to these interventions are presented in the Resource section.
A forcing function or constraint is a process or equipment design feature that makes it easy to do the right thing. Forcing functions can be built into free text data entry fields in electronic health records by not accepting certain abbreviations (forced correction) or by automatically converting short forms of communication into an acceptable format (auto-correction). One study showed that alerts with a forced correction feature decreased the use of abbreviations to a much greater extent than alerts with an auto-correction feature.46
A pharmacy purchasing solution to reduce abbreviation use is to avoid pharmaceuticals that are labelled with error-prone abbreviations or other short forms that could create a hazard. Report problem labelling to the manufacturer and ISMP Canada.47
Enforcement is a type of forcing function that is used with abbreviations or other unacceptable ordering practices. A policy is developed that requires clarification with the prescriber of orders containing an unapproved abbreviation before the order can be followed. While enforcement seems like a logical solution, evidence of effectiveness is lacking.48 Enforcement can create inter-professional friction, be time-consuming, and result in delayed therapy for patients.49 Enforcement is rarely the first option but some initiatives have resorted to it when other interventions did not reduce abbreviation use to the desired level.11
The use of information technology in healthcare is an example of a system-based strategy with a high level of effectiveness.31 Initially it was assumed that technology would eliminate the problem of unsafe abbreviations; however, experience has shown that while technology solves some problems, it creates other issues.41
Computerized prescriber order entry (CPOE) and electronic health/medical records
Computerized prescriber order entry (CPOE) and electronic prescribing help to standardize medication prescribing, eliminate illegible orders, and curtail the use of error-prone abbreviations. It can take the form of a stand-alone program or be embedded within an electronic health record. The system needs to be designed to minimize the use of abbreviations.42,43 Studies have shown that computer technology can significantly reduce the use of abbreviations in prescription orders, but it is not as effective in reducing abbreviation use with other forms of documentation in the medical record where free-text entry is common.13 When purchasing technology, look closely at the design and function of the system, including how information is displayed on screen and the safety features intended to minimize the use of abbreviations.44
Pharmacy dispensing systems and electronic reports
Pharmacy systems, labels, and reports need to be free of abbreviations and shortened medication names.45 Scrutinize new technologies and products prior to purchase to minimize the risk of introducing abbreviations into the dispensing system. The pharmacy can assist organizations by providing computer generated medication administration records (MAR) or more advanced electronic MAR (e-MAR) systems, which will help standardize medication entries and eliminate the need for staff to transcribe new or changed orders.
SUGGESTIONS RELATED TO COMPUTERIZATION
- When purchasing a software system look for a vendor who can support the ‘Do Not Use’ abbreviation policy, both on-screen and when producing reports.
- Work with your existing software vendor to remove error-prone abbreviations and/or program the computer to reject abbreviations, such as from free-text entry fields.
- Consider a clinical decision support tool that will provide alerts to manage abbreviations.
- Avoid abbreviations on pharmacy-generated labels, storage bins and shelves, medication administration records, and pre-printed order forms.45
Standardization of Orders
The use of protocols or pre-printed clinical order sets (paper or electronic) that do not use abbreviations can help structure medication ordering and support clear communication.40 Use check boxes on preprinted or electronic forms to limit the use of handwritten order components or free-text entry. The Resources section includes an example of a checklist developed by a health organization to assist their facilities in reviewing standing orders or medication protocols for adherence to order-writing standards.
Audit and Feedback
Audit (measurement of current practice) and either general or personal feedback serves both an education and a reminder function. It can be an effective practice change tool. General feedback can take the form of a graph showing progress with measures related to the initiative over time (run chart) posted in an area where it can be seen by frontline providers. Personal feedback can be provided to individual providers showing how their use of abbreviations compares to that of aggregated data from their peers. Personalized measurement and feedback is most effective when an individual is under-performing, the feedback is given more than once, and is delivered by a supervisor or colleague. 39 Some studies noted that feedback can be very resource intensive and not always sustainable.11,28 Suggestions for using audit and feedback are presented below.
SUGGESTIONS FOR USING AUDIT AND FEEDBACK
- Document the use of error-prone abbreviations before the initiative and monitor the change in use as different interventions are tried. Post the results in areas where they are visible to frontline providers.
- Send targeted reminders to individual prescribers when an order or clinical note includes an unapproved abbreviation.
- Provide de-identified peer comparison feedback to prescribers to show them how their use of the targeted abbreviation(s) compares to that of their colleagues.
- Consider providing positive reinforcement by providing feedback on the use of the preferred format or when abbreviations are not used.
Most initiatives use some form of reminder or prompt to reinforce key messages from the educational sessions. This can take the form of a personal prompt such as a phone call or note (actions that are typically specified in a policy or guideline document), or a general reminder such as a poster, or a reminder of expected practice incorporated into the order sheet or order entry screens. Suggestions related to reminders are presented below.
SUGGESTIONS FOR USE OF REMINDERS
- Create and use a slogan to encourage compliance, such as ‘Write It Out.’
- Provide staff with pocket size laminated cards with a printed list of error-prone abbreviations to avoid, preferred alternatives to abbreviations, and common approved abbreviations.
- Print a list of unapproved abbreviations and the preferred alternatives on physician order sheets, medication reconciliation forms, and progress notes.
- Place a reminder on the front of the patient’s or resident’s health record.
- Develop a coloured poster or cards with the list of error-prone abbreviations and their preferred alternatives to place in areas where care providers write or transcribe orders.
- Contact the Health Quality Council of Alberta (HQCA) or other safety organizations for promotional material to support an abbreviation initiative.
- Print the ‘Do Not Use’ or ‘Please Use’ list on promotional material such as pens, note pads, magnets, or mouse pads.
- Post the ‘Do Not Use’ or ‘Please Use’ list as a screen saver on the computer or feature a different error-prone abbreviation each month.
Policies and Guidelines
The development of a policy is often the first step taken by an organization and is a prerequisite for any type of enforcement strategy. Policies and guidelines can address order writing or documentation in the health record in general, or specifically focus on abbreviation use. Abbreviation-focused policies can address the issue generally or target specific error-prone abbreviations or practices known to be an issue in that setting. However, developing and implementing a policy alone will not be successful in creating change. Other change strategies will be required to implement the policy. Suggestions for policy and guideline development are found below.
SUGGESTIONS FOR POLICY AND GUIDELINE DEVELOPMENT
- Determine the list of abbreviations, symbols and dose expressions which will not be used. Consider adopting the current ISMP Canada ‘Do Not Use’ list if that is appropriate for the local setting.
- List the types of communications where error-prone abbreviations will not be used, such as written orders, transcription of verbal orders, medication reconciliation forms, or handwritten medication administration records (e.g., in continuing care). When an electronic health record is being used, the policy should address how abbreviations are used in free text fields.33
- Determine how staff will manage orders containing error-prone abbreviations, including expectations regarding notifying the prescriber. Consider requiring clarification when an error-prone abbreviation is used to order a high-alert medication.
- Work collaboratively with a network of other care settings in the area (e.g., local acute care hospital, continuing care sites, primary care network, pharmacies, and home care) to establish a common list of abbreviations that should not be used and a common approach to managing error-prone abbreviations. This will support consistent practice across settings and protect patients during transitions in care.
Education and Awareness
In order to be effective, educational interventions should be tailored to the needs of the group expected to change their practice. Several studies noted success with educational sessions for prescribers focused on safe prescribing practices or on abbreviation use in medication ordering.13,27,34-38
Organizations are replacing traditional in-person presentations with easily accessible e-learning modules. Both forms of education have their merits and challenges, and should be selected and designed carefully with the needs of the target group in mind. Suggestions for developing an education program or awareness campaign are presented below.
SUGGESTIONS FOR DEVELOPING AN EDUCATION PROGRAM OR AWARENESS CAMPAIGN
- Inform all staff, contracted care providers (e.g., doctors, pharmacies who provide service to continuing care sites), and students who are involved in ordering, transcribing, or documenting patient care of the policy, list of unapproved abbreviations and related safety issues.
- Consider including other staff in the education program whose activities could impact abbreviation use such as front line managers, unit clerks, purchasing staff, and quality and risk management staff.
- Add the issue of abbreviations to committee agendas e.g., Medication Safety and Advisory Committee, Pharmacy and Therapeutics Committee, Medical Advisory Committee, Quality and Safety Committee.
- Give updates about the safety initiative at unit, department, or medical staff meetings.
- Develop an educational presentation using examples of the harm that the target abbreviations and poor handwriting can cause. If possible, use examples from your setting, pharmacy, or clinic.
- Provide one-on-one educational sessions with a prescriber or staff member who continues to use error-prone abbreviations.
- Create an educational display for Patient Safety Week.
- Conduct an electronic poll to test staff about their knowledge of abbreviations.
- Place an article in the monthly newsletter.
- Encourage staff to remind each other not to use unapproved abbreviations.
- Consider asking staff to sign a statement that they have received the list and have agreed to not use these error-prone abbreviations.
- Consider providing education at the local primary care network or clinic that highlights the problems with the use of abbreviations.
- Collaborate with other care settings in the area on an abbreviation initiative with a broader impact that crosses multiple transitions in care (e.g., pharmacies, primary care network or clinics, home care, continuing care and supportive living sites).
Challenges to reducing the use of abbreviations are as varied as the different ways that abbreviations can contribute to errors. Overcoming these challenges requires a multifaceted change initiative that engages a wide variety of healthcare providers. These strategies are mainly applicable to healthcare delivery sites although pre-professional education programs for healthcare providers can use some of these strategies to help create a culture of practice in which abbreviation use is minimized. Finally, there are many things that individual healthcare providers can do in their personal practice to impact abbreviation use.
A table summarizing challenges and barriers as well as possible strategies to address them is found in the Resource section below. The following areas are covered:
- Limited reporting of abbreviation-related errors.
- Today’s culture reinforces use of abbreviations and other communication short-cuts.
- Limited knowledge of patient safety concerns with abbreviations.
- Variable prescribing practices.
- Variable documentation and transcription skills.
- Poorly designed technology.
Brief description of selected abbreviation initiatives from Canada.
Table listing challenges to changing behaviours related to abbreviations and possible strategies.
Short description of websites and textbooks that provide useful information to support an abbreviation initiative.
The HQCA has developed a set of five bookmarks to highlight five common error-prone abbreviations: U and IU for units, QD and OD for daily, leading and trailing zeros, abbreviated medication names.
The HQCA has developed a checklist that health professions educators can use to review strategies to promote clear communication and discourage abbreviation use by their students.
Table summarizing research that documents effectiveness of different abbreviation intervention strategies.
Example of a checklist that was developed to guide a review of how standing orders and pre-printed orders comply with the organization’s medication order writing standards. Abbreviation use is addressed.
Description of a process and tool that frontline staff can use to assess medication order writing practices in their care area.
Example of a physician order and progress record from continuing care that incorporates a reminder about abbreviation standards.