Medication Safety Collaborative

Improving Prescribing in the Emergency Department

Team: JENNY BAKER Technical Expert, Quality Resource Unit DARRELL DUNCAN Executive Sponsor DIANE REEVES Pharmacy Leader
DECLAN STEWART Medical Leader, Emergency Medicine Staff Specialist FIONA WILKINSON Project Co-ordinator, Emergency Nursing. Supports: Kerry Davison & Dr Scott Whyte

STRATEGIES/INITIATIVES CONCLUSIONS
1. Best practice prescribing 2. Medication History Stamp Patient flow, staffing and rotation of medical terms all produce variances in
During 2004 Central Coast Health participated in the ID Card Attachment the prescribing accuracy of medications for patients admitted through the
National Medication Safety Breakthrough Collaborative. IS PATIENT ON: YES NO
Emergency Department.
Medications
Our aim was to improve prescribing habits of medical officers
Best Practice Prescribing Acceptable Abbreviations
if in doubt CHECK
Inhalers
Eye drops




These factors contribute to the rate of prescribing error in The Emergency
1. Patient identified by name, MRN and DOB

within the Emergency Departments of both Gosford and Wyong 2. Prescriber is identified by PRINTED
INSTRUCTION
Daily
ABBREVIATION
Daily or mane, midi
Non-Script items/Herbal
HAS PATIENT:

Department.
NAME or pager number or nocte
Twice daily bd
Recently changed medication
Hospital. Data collected during this collaborative indicated poor 3. ADR box always filled in Three times daily
Four times daily
tds
qds or qid
Brought in own medications Applying these error rates to projected admissions through Gosford ED
4. Legible prescriptions

prescriber habits such as illegibility, non-compliance to local 5. S8 frequency and maximum number of
Every x hours

REMEMBER
qxh eg, q6h
every 6 hours
WHY
show significant improvements can be achieved with continued
doses stated

guidelines, poor compliance with ADR completion and poor 6. Weight of patients especially children and
PUT a zero before a
decimal point
DONT put zeros
1 has been read as 1

1 0 has been read as 10

targeted interventions.
for antibiotics and Enoxaparin after decimal point

prescriber identification during medication prescribing. Initiative Medication Safety Collaborative

DONT use U or IU
for units
DONT use od for
10U has been read
as 100
od has been read as bd TABLE 4
Quality Resource Unit
Central Coast Health daily

Most patients presenting to Central Coast Health are admitted

Write full names for all chemotherapeutic agents
Extrapolated Yearly Prescribing Errors Pre and Post Intervention
Targeted Parameters Patients Presenting via ED (Gosford Hospital)
through its Emergency Departments and hence have their 3. Prompt sticker package; applied to ED progress note holders
medications charted by Emergency Medical Officers. 20000
18642
17448 17625
Our team hypothesised that the majority of errors occurring due Pre-intervention

Extrapolated errors p.a.

15000 Post-intervention
to medication prescribing would occur here, and if targeted with 13229 13075
11584

educational intervention, would produce a reduction in harm and 10000

have a flow-on effect throughout the organisation and community. 5000

5221 5020

With the development of several key initiatives by the collaborative

team medical officers in ED improved many areas of prescribing. 0

ID inadequate Allergy documentation Frequency Route

Parameter

TEAM AIMS THE FUTURE

To improve the safety of medications for patients admitted Maintain reduction in harm or potential for harm from medication
through ED. prescribing error

To improve the prescribing practice of Medical Officers
within the ED.
To increase awareness of medication safety and error
management by nursing and medical staff in the ED.
Identify prescribers in need of further education to improve their prescribing
habits. Targeted continuing education will be the fundamental component of
4. Medication Chart Folder Divider this initiative.
Establish a medical officer signature database to allow identification of
MEDICATION

Identify hospital-accepted abbreviations and encourage prescribing Medical Officers

compliance. Identify poor prescriber groups and adapt specific education packages to
CHARTS

MEDICATION CHARTS
suit their needs.
Identification of prescriber (legible printing of prescribers
surname and/or page number). OK TO USE
THESE ABBREVIATIONS DO NOT USE
THESE ABBREVIATIONS Implement withhold medication chart to reduce the incident rate of u
MEDICATION charted drug omissions.
AVOID THESE INTENDED
DOSE FREQUENCY OR TIMING ROUTE OF ADMINISTRATION ABBREVIATIONS MEANING WHY? WHAT SHOULD I USE?

mane morning INH Inhale OD, o.d. Once daily OD can be mistaken as Use daily

Identification of local guidelines, increase awareness and midi midday IM intramuscular TIW Three times a week
twice a day
Mistaken as three times Write out in full and specify

CHARTS
a day which days
nocte night Intrathecal intrathecal
sc subcutaneous Mistaken for sublingual Use subcut or write

Spread use of medication chart folder dividers throughout organisation

b.d. twice daily IV intravenous subcutaneous

compliance. t.d.s.
q.i.d. or q.d.s.
4 hourly (or q4h)
three times daily
four times a day
every 4 hours
NG
PO
PV
naso-gastric
Oral
per vagina
q.d. or QD

IU
eg, 3 iu
cc
every day

International unit

cubic centimetres
Mistaken as Q.I.D. or four
times a day
Misread as IV (intravenous)
or misread as 31 U
Misread as u when
Use daily

Use units

Use mL
6 hourly (or q6h) every 6 hours PR per rectum handwritten

Introduction of clinical pharmacist review.

8 hourly (or q8h)
p.r.n.
stat.
every 8 hours
when required
immediately
TOP
SUBCUT
NEB
Topical
Subcutaneous
Nebulised

g

x3d
> or <
microgram

For 3 days
Greater than
Mistaken as milligram
when handwritten
Mistaken as three doses
Opposite of intended
Write out in full

Use for three days

Use greater than or less than
A medication safety team should continue comprising representatives from
or less than

Pharmacy, Quality, Medical and Nursing, sponsored by QRU.

a.c. before food
Zero after a decimal 5 mg Misread as 50mg if decimal Do not use decimal points after
p.c. after food point eg, (5.0) point not seen whole numbers
No decimal point 0.5mg Misread as 5 mg Always use a zero before decimal

Improve medication history documentation. g

UNITS OF MEASURE
gram(s)
before fractional
dose eg, (.5mg)
Chemical symbols
eg, NaHCO3
Sodium bicarbonate May not be understood
when dose is less than one

Write out in full

L
mg
litre(s)
milligrams(s)
IT
Drug names; eg,
epo
Intrathecal
erythropoetin
Misread as IV
Mistaken as evening
primrose oil
Write out in full
Write all drug names out in full
generic name for single active
Continue audit and review of prescribing habits with reporting through the
Reduce prescribing, omission and transcription errors. mL
microgram (NEVER mcg or
g)
Unit(s) (NEVER I.U or U)
millilitre(s)
microgram(s)
International Unit(s)
6/24
1/7
Every six hours
For one day
Mistaken as six times a day
Mistaken for one week
ingredient, and trade name for
combination drugs
Use q6h or 6 hourly
Write out for one day
Quality Resource Unit to the Central Coast Quality Committee.
e ear or eye Misinterpreted as the other Write ear or eye
organ
ADAPTED WITH PERMISSION FROM THE NATIONAL PRESCRIBING SERVICE

Improve compliance with ADR documentation on

D/C Discharge or Misinterpreted as the other Write out discontinue or
discontinue intention discharge

rative
CCH3201Q/DEC04

Incorporate auditing of medication charts as part of teaching and training in

medication charts. Initiative Medica
Contact: Quality
tion Safety Collabo
Resource Unit,
Central Coast
Health

the Emergency Department may help to bridge the gap between prescribing
and recognition of error.

METHODOLOGY TABLE 5
RESULTS Extrapolated Yearly Drug Dosing Error
Utilising the clinical practice improvement
model and the PDSA Cycle our team
TABLE 1 100 Projected 20824
accurately identified areas to target. Complete ADR Documentation %

Trend of Emergency 80
Transcription Error %
Accurate and complete charts %

Baseline data was collected to measure the Department medication

accuracy of Medical Officer prescribing with 60
Percentage

chart prescribing Current 20476

initial data collection attended in November accuracy in relation to 40

2003 and secondary review in June 2004 medical staff rotation 20 20000 20250 20500 20750 21000

Fortnightly data collection continued throughout the period 0

Extrapolated errors pa patients presenting via ED

of the collaborative in both Ward 6 (EMU) and The Emergency Jan * Feb Mar Apr * May Jun * Jul Aug * Sept Oct *

Month (* indicates medical staff rotation) Dosing error consisted of incorrect drug dose, abbreviation or documentation.
Departments.
There was no improvement in overall dosing error despite our multi-faceted
Educational intervention commenced two months after the intervention targeting medication history, accuracy and documentation.
TABLE 2
initial data collection and was designed to become embedded This indicates an ongoing need to re-assess and target this particular area
Percentage of patients who have a medication history including
in the normal processes of the Emergency Department and of prescribing error.
ADR documented within 24 hours of admission
hence is ongoing.

100
COLLABORATIVE BENEFITS
KEY INITIATIVES % 60
80

40
20
The program quantified the areas of concern, if you cant measure it,
Best Practice Prescribing Card attached to MO (Medical Officer) 0 you cant manage it.
Feb 04

Mar 04

Apr04

May 04

Jun 04

Jul 04

Aug 04

Sep 04

Oct 04

ID tags. Auditing the issues raised heightened awareness and the necessity for
MO Orientation package A 60% increase in documentation of ADR in medication chart Allergy Box continued monitoring of medication prescribing.
Medication history stamp inserted into history & progress With all initiatives adapted to meet our local needs our program highlighted
notes to replace existing medication history documentation that safety is a system priority.
format. TABLE 3
The realisation that simple, commonsense changes can reduce error
Percentage of patients with accurate, complete and legible
ED prompt sticker package applied to ED history & progress and potential harm.
medication charts
note holders. Increased awareness of medication safety and the potential for harm
100
Nursing and Medical in-service program 80
resulting from medication errors.
Modification of ED Progress Notes to accommodate new % 60 Increased assertiveness of nursing staff and recognition of potential harm.
40
prompt format for nurse medication history. Recognition of standard abbreviations and local prescribing policies.
20
Folder dividers to separate medication charts in patient bed- 0 Improved prescribing practises.
Feb 04

Mar 04

Apr04

May 04

Jun 04

Jul 04

Aug 04

Sep 04

Oct 04

notes, containing acceptable abbreviations as prompt to MOs. Increased staff awareness of the need for accurate medication history
Provision of clinical pharmacist to Gosford Emergency taking and subsequent risks of potential harm.
A 60% increase in complete, accurate and legible medication charts
Department, and twice weekly visits to Wyong Emergency Development of interventions that have application
Department. throughout our organisation and
Review of medication incidents through drug committee. within other Health Services. Northern Sydney
Central Coast Health
NSCCH3439Q/FEB05