5 Storyboard (Contoh 1)

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
During 2004 Central Coast Health participated in the

National Medication Safety Breakthrough Collaborative.
Our aim was to improve prescribing habits of medical officers
within the Emergency Departments of both Gosford and Wyong
Hospital. Data collected during this collaborative indicated poor
prescriber habits such as illegibility, non-compliance to local
guidelines, poor compliance with ADR completion and poor
prescriber identification during medication prescribing.
STRATEGIES/INITIATIVES
CONCLUSIONS
1. Best practice prescribing

ID Card Attachment
Patient flow, staffing and rotation of medical terms all produce variances in
the prescribing accuracy of medications for patients admitted through the
Emergency Department.
2. Medication History Stamp
Best Practice Prescribing
Acceptable Abbreviations
1. Patient identified by name, MRN and DOB
if in doubt CHECK
2. Prescriber is identified by PRINTED

NAME or pager number
INSTRUCTION
ABBREVIATION
Daily
Daily or mane, midi

or nocte
bd
tds
qds or qid
qxh eg, q6h
every 6 hours
Twice daily
Three times daily
Four times daily
Every x hours
3. ADR box always filled in

4. Legible prescriptions
5. S8 frequency and maximum number of
doses stated
6. Weight of patients especially children and
for antibiotics and Enoxaparin
Initiative Medication Safety Collaborative
Quality Resource Unit
Central Coast Health
REMEMBER
WHY
PUT a zero before a

decimal point
DONT put zeros
after decimal point
DONT use U or IU
for units
DONT use od for
daily
IS PATIENT ON:
Medications
Inhalers
Eye drops
Non-Script items/Herbal
HAS PATIENT:
Recently changed medication
Brought in own medications
YES
NO
These factors contribute to the rate of prescribing error in The Emergency

Department.
Applying these error rates to projected admissions through Gosford ED
show significant improvements can be achieved with continued
targeted interventions.
has been read as 1
1 0 has been read as 10

10U has been read
as 100
od has been read as bd
Write full names for all chemotherapeutic agents
3. Prompt sticker package; applied to ED progress note holders
20000
Pre-intervention
Extrapolated errors p.a.
Most patients presenting to Central Coast Health are admitted

through its Emergency Departments and hence have their
medications charted by Emergency Medical Officers.
Our team hypothesised that the majority of errors occurring due
to medication prescribing would occur here, and if targeted with
educational intervention, would produce a reduction in harm and
have a flow-on effect throughout the organisation and community.
With the development of several key initiatives by the collaborative
team medical officers in ED improved many areas of prescribing.
TABLE 4
Extrapolated Yearly Prescribing Errors Pre and Post Intervention
Targeted Parameters Patients Presenting via ED (Gosford Hospital)
18642
17625
17448
Post-intervention
15000
13229
13075
11584
10000
5221
5000
5020
ID inadequate
Allergy documentation
Frequency
Route
Parameter
TEAM AIMS
THE FUTURE
To improve the safety of medications for patients admitted

through ED.
Maintain reduction in harm or potential for harm from medication

prescribing error
To improve the prescribing practice of Medical Officers

within the ED.
Identify prescribers in need of further education to improve their prescribing

habits. Targeted continuing education will be the fundamental component of
this initiative.
4. Medication Chart Folder Divider
Identify hospital-accepted abbreviations and encourage

compliance.
Identification of prescriber (legible printing of prescribers
surname and/or page number).
MEDICATION
CHARTS
Identification of local guidelines, increase awareness and

compliance.
Establish a medical officer signature database to allow identification of

prescribing Medical Officers
CHARTS
MEDICATION
To increase awareness of medication safety and error

management by nursing and medical staff in the ED.
MEDICATION CHARTS
mane
midi
nocte
Introduction of clinical pharmacist review.

Improve medication history documentation.
OK TO USE
THESE ABBREVIATIONS
DOSE FREQUENCY OR TIMING
AVOID THESE
ABBREVIATIONS
ROUTE OF ADMINISTRATION
morning
INH
Inhale
midday
night
IM
Intrathecal
b.d.
t.d.s.
twice daily
three times daily
IV
NG
intravenous
naso-gastric
q.i.d. or q.d.s.
4 hourly (or q4h)
6 hourly (or q6h)
four times a day

every 4 hours
every 6 hours
PO
PV
PR
Oral
per vagina
per rectum
intramuscular
intrathecal
8 hourly (or q8h)
every 8 hours
TOP
Topical
p.r.n.
stat.
a.c.
p.c.
when required
immediately
before food
after food
SUBCUT
NEB
Subcutaneous
Nebulised
UNITS OF MEASURE
Reduce prescribing, omission and transcription errors.
g
L
mg
gram(s)
litre(s)
milligrams(s)
mL
millilitre(s)
microgram (NEVER mcg or g)

Unit(s) (NEVER I.U or U)
microgram(s)
International Unit(s)
DO NOT USE
THESE ABBREVIATIONS
INTENDED
MEANING
OD can be mistaken as
twice a day
Use daily
TIW
Three times a week
Mistaken as three times

a day
Write out in full and specify

which days
sc
subcutaneous
Mistaken for sublingual
Use subcut or write

subcutaneous
q.d. or QD
every day
Mistaken as Q.I.D. or four

times a day
Use daily
IU
eg, 3 iu
International unit
Misread as IV (intravenous)
or misread as 31 U
Use units
cc
cubic centimetres
Misread as u when
handwritten
Use mL
g
microgram
Mistaken as milligram
when handwritten
Write out in full
Utilising the clinical practice improvement

model and the PDSA Cycle our team
accurately identified areas to target.
Baseline data was collected to measure the
accuracy of Medical Officer prescribing with
initial data collection attended in November
2003 and secondary review in June 2004
x3d
For 3 days
Mistaken as three doses
Use for three days
> or <
Greater than
or less than
Opposite of intended
Use greater than or less than
Zero after a decimal

point eg, (5.0)
5 mg
Misread as 50mg if decimal

point not seen
Do not use decimal points after

whole numbers
No decimal point
before fractional
dose eg, (.5mg)
0.5mg
Misread as 5 mg
Always use a zero before decimal

when dose is less than one
Chemical symbols
eg, NaHCO3
Sodium bicarbonate May not be understood
IT
Intrathecal
Misread as IV
Write out in full
Drug names; eg,

epo
erythropoetin
Mistaken as evening
primrose oil
Write all drug names out in full

generic name for single active
ingredient, and trade name for
combination drugs
6/24
Every six hours
Mistaken as six times a day
Use q6h or 6 hourly
1/7
For one day
Mistaken for one week
Write out for one day
ear or eye
Misinterpreted as the other

organ
Write ear or eye
D/C
Discharge or
discontinue
Misinterpreted as the other

intention
Write out discontinue or

discharge
RESULTS
TABLE 1
Trend of Emergency
Department medication
chart prescribing
accuracy in relation to
medical staff rotation
100
80
60
20000
20
20250
20500
20750
21000
0
Jan *
Feb
Mar
Apr *
May
Jun *
Jul
Aug *
Sept
Oct *
Month (* indicates medical staff rotation)
TABLE 2
Percentage of patients who have a medication history including
ADR documented within 24 hours of admission
Dosing error consisted of incorrect drug dose, abbreviation or documentation.

There was no improvement in overall dosing error despite our multi-faceted
intervention targeting medication history, accuracy and documentation.
This indicates an ongoing need to re-assess and target this particular area
of prescribing error.
COLLABORATIVE BENEFITS
80
% 60
Oct 04
Sep 04
Aug 04
Jul 04
Jun 04
May 04
Apr04
Mar 04
Feb 04
A 60% increase in documentation of ADR in medication chart Allergy Box
The program quantified the areas of concern, if you cant measure it,
you cant manage it.
Auditing the issues raised heightened awareness and the necessity for
continued monitoring of medication prescribing.
With all initiatives adapted to meet our local needs our program highlighted
that safety is a system priority.
TABLE 3
Percentage of patients with accurate, complete and legible
medication charts
The realisation that simple, commonsense changes can reduce error

and potential harm.
Increased awareness of medication safety and the potential for harm
resulting from medication errors.
100
Nursing and Medical in-service program

Modification of ED Progress Notes to accommodate new
prompt format for nurse medication history.
20476
Current
40
20
ED prompt sticker package applied to ED history & progress

note holders.
20824
Projected
Extrapolated errors pa patients presenting via ED
Best Practice Prescribing Card attached to MO (Medical Officer)

ID tags.
Medication history stamp inserted into history & progress
notes to replace existing medication history documentation
format.
Incorporate auditing of medication charts as part of teaching and training in

the Emergency Department may help to bridge the gap between prescribing
and recognition of error.
Complete ADR Documentation %

Transcription Error %
Accurate and complete charts %
40
MO Orientation package
Continue audit and review of prescribing habits with reporting through the
Quality Resource Unit to the Central Coast Quality Committee.
TABLE 5
Extrapolated Yearly Drug Dosing Error
100
KEY INITIATIVES
A medication safety team should continue comprising representatives from

Pharmacy, Quality, Medical and Nursing, sponsored by QRU.
Write out in full
CCH3201Q/DEC04
Fortnightly data collection continued throughout the period

of the collaborative in both Ward 6 (EMU) and The Emergency
Departments.
Educational intervention commenced two months after the
initial data collection and was designed to become embedded
in the normal processes of the Emergency Department and
hence is ongoing.
Implement withhold medication chart to reduce the incident rate of u

charted drug omissions.
Spread use of medication chart folder dividers throughout organisation
rative
tion Safety Collabo
Health
Central Coast
Initiative Medica
Resource Unit,
Contact: Quality
Percentage
METHODOLOGY
WHAT SHOULD I USE?
Once daily
ADAPTED WITH PERMISSION FROM THE NATIONAL PRESCRIBING SERVICE
Improve compliance with ADR documentation on

medication charts.
WHY?
OD, o.d.
Identify poor prescriber groups and adapt specific education packages to

suit their needs.
80
Increased assertiveness of nursing staff and recognition of potential harm.
60
40
Recognition of standard abbreviations and local prescribing policies.
20
Oct 04
A 60% increase in complete, accurate and legible medication charts
Sep 04
Aug 04
Jul 04
Jun 04
May 04
Apr04
Review of medication incidents through drug committee.
Improved prescribing practises.

Mar 04
Provision of clinical pharmacist to Gosford Emergency

Department, and twice weekly visits to Wyong Emergency
Department.
Feb 04
Folder dividers to separate medication charts in patient bednotes, containing acceptable abbreviations as prompt to MOs.
Increased staff awareness of the need for accurate medication history

taking and subsequent risks of potential harm.
Development of interventions that have application
throughout our organisation and
within other Health Services.
Northern Sydney
Central Coast Health
NSCCH3439Q/FEB05

5 Storyboard (Contoh 1)

Uploaded by

Copyright:

Available Formats

5 Storyboard (Contoh 1)

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

5 Storyboard (Contoh 1)

Uploaded by

Copyright:

Available Formats

Medication Safety Collaborative

Improving Prescribing in the Emergency Department

During 2004 Central Coast Health participated in the

1. Best practice prescribing

2. Medication History Stamp

Best Practice Prescribing

1. Patient identified by name, MRN and DOB

2. Prescriber is identified by PRINTED

Daily or mane, midi

3. ADR box always filled in

PUT a zero before a

These factors contribute to the rate of prescribing error in The Emergency

has been read as 1

1 0 has been read as 10

Write full names for all chemotherapeutic agents

3. Prompt sticker package; applied to ED progress note holders

Most patients presenting to Central Coast Health are admitted

To improve the safety of medications for patients admitted

Maintain reduction in harm or potential for harm from medication

To improve the prescribing practice of Medical Officers

Identify prescribers in need of further education to improve their prescribing

4. Medication Chart Folder Divider

Identify hospital-accepted abbreviations and encourage

Identification of local guidelines, increase awareness and

Establish a medical officer signature database to allow identification of

To increase awareness of medication safety and error

Introduction of clinical pharmacist review.

DOSE FREQUENCY OR TIMING

four times a day

8 hourly (or q8h)

Reduce prescribing, omission and transcription errors.

microgram (NEVER mcg or g)

Three times a week

Mistaken as three times

Write out in full and specify

Mistaken for sublingual

Use subcut or write

Mistaken as Q.I.D. or four

Write out in full

Utilising the clinical practice improvement

Mistaken as three doses

Use for three days

Use greater than or less than

Zero after a decimal

Misread as 50mg if decimal

Do not use decimal points after

Always use a zero before decimal

Sodium bicarbonate May not be understood

Write out in full

Drug names; eg,

Write all drug names out in full

Every six hours

Mistaken as six times a day

Use q6h or 6 hourly

For one day

Mistaken for one week

Write out for one day

Misinterpreted as the other

Write ear or eye