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