Bite-Size: Safe Medical Practice in Abbreviations and Verbal Orders.
Introduction
A new blog concept for my website. These blogs tend to be small and introduce a concept or talks about an experience I had. Bite-size blogs should be a little less than 2 minutes read and may be less than 600 words. Nothing too prominent with a relaxed feel to it and no insane reference list.
In this edition of Bite-Size, I wanted to talk about two topics regarding safe medical practices in the healthcare system. That is the use of abbreviations and dose designations, and the writing of verbal orders (VO). I thought these topics are interesting, relevant and have quite an impact on health.
Abbreviations and dose designations
There should be only a national standardised abbreviations and dose designations lists to which they must be carefully checked.
Introduction
Since the dawn of modern medicine, the use of abbreviations is frequent and daily and has been thoroughly ingrained in medicine. Abbreviations were initially only used in prescriptions, but over time its appearance has become usual in almost every documentation such as presenting cases, surgical orders/descriptions, discharge et cetera.
The most worrying concerns are abbreviations used for drug orders where the outcomes are adverse effects amplifications or overdose or underdose or even the wrong medication, which could have significant consequences such as death. Before recent changes, abbreviations were not regulated to which there are no universal rules, and in some cases, healthcare professionals make up their own abbreviations. In some medical schools, the abbreviations start as early as the first year and customise the students to abbreviate. Interestingly, some hospitals have their own specialised list of abbreviations. It was found that abbreviations account for 5% in medication errors where QD for once daily represented 43.1% of errors followed by U for units (13.1%), cc for mL (12.6%) and MSO4 for morphine (9.7%).
If abbreviations were to be tackled as an issue, a vicious cycle may be introduced. For example, there is now an increase pressure on the pharmacy and nursing staff to contact the physician to clarify on the prescription or order, which wastes time for everybody out of their busy days. Abbreviations were meant to save time but the misuse creates more confusion, time wasting and potential adverse effects. Introducing a method to double check thus waste more time and may cause more pressure, which may increase burnouts. This is exacerbated if there is a shortage of staff.
Professionalism requirement
- Pass the abbreviation course as a hospital hurdle requirement. This course includes education on the misuse of abbreviations and its harm that it may cause.
Recommendations
Educate staff on the harm of abbreviations. All staff should undergo mandatory training that is set by the national medical association.
Use the national abbreviation system.
Enforcement and accountability should be introduced.
Prohibition reminders on patient's chart, posters, newsletter, computer screen savers, announcement boards and main hospital website.
Introduce computerized physician order entry (CPOE) systems. Such as introducing electronic usage may decrease errors as programs can have abbreviations lists.
Leadership and behaviour changes need to be tackled to implement change and remove any form of hierarchical peer pressure.
Frequent auditing.
Add a complaint system.
Develop a committee.
Conclusion
While abbreviation can be useful and efficient, they can also be harmful. But the good news is that there are solutions and the main aim is to achieve zero error within a hospital setting. Junior doctors and other staff should not be left alone to decipher instructions, especially in high stress and impact environment. To stop these errors, education and accountability are essential. To conclude: be mindful what you write and follow the guideline, wouldn’t you like a chart with clear abbreviations and hand writing (especially when you are tired)?
Verbal orders should be recorded
Verbal orders should be recorded whenever possible and immediately read back to the prescriber; that is, a health care provider receiving a verbal order should read or repeat back the information that the prescriber conveys in order to verify the accuracy of what was heard.
Introduction
Eventually, a physician will not be present with other health care staff to transfer crucial information and prescription orders. An easy and straightforward solution is to present the information through verbal orders (VO), which enables the recipient to act out what is needed rapidly and efficiently. Under the law and its regulation, a person of power to prescribe is allowed to give a VO, which includes face to face or telephonic calls.
There are strict processes to record a VO, which includes the recipient, who has to be a valid healthcare staff that suits their role, to read back to the prescriber, which should be confirmed. A cosigner has to authenticate the VO by also repeating and verifying to the caller. This method is successful in terms of making sure the appropriate information has been translated. For example, I know I have an accent and I have noticed people who did not understand me clearly or thought I said something else. This is very useful in ensuring second language speakers are understood.
Professionalism requirement
- Pass the hurdle on how to give a hospital approved VO with its allocated process.
- Having an adequate mark on the IELTS/TOFEL.
Recommendations
Educate staff on the harm of unsuccessful VO. All staff should undergo mandatory training that is set by the national medical association.
Use the national VO process.
VO should be limited and used in urgent situations (such as VO should not be used just because it is the easier option or suits the person better).
Establish policies on VO.
Medication such as antineoplastic drugs should never be used in VO.
Enforcement and accountability should be introduced.
Second-language speakers need to pronounciate properly and must be aware of their accents.
Use of posters, newsletter, computer screen savers, announcement boards, acronyms and main hospital website on the harm of VO.
Frequent auditing.
Add a complaint system.
Develop a committee.
Conclusion
Verbal orders may be beneficial in certain circumstances and may save much time; however, safe prescribing and transmission of knowledge need to be strictly implemented as there could be drastic consequences.
Published 20th August 2020. Last reviewed 1st December 2021.
Reference
AHRQ authors. 30 Safe practices for better health care. AHRQ.gov website. Published March, 2005. Accessed August 10, 2020.
Arevalo JD. Abbreviations may save minutes; prohibiting abbreviations may save lives. AMN Healthcare. https://www.amnhealthcare.com/latest-healthcare-news/abbreviations-may-save-minutes-prohibiting-abbreviations-may-save-lives/. Published 2007. Accessed August 16, 2020.
Moghaddasi H. Verbal Orders in Medicine: Challenges; Problems and Solution. JOJ Nurse Health Care. 2017; 1(5): 555575.
Patient Safety Authority authors. Improving the Safety of Telephone or Verbal Orders. Patient Safety Authority website. http://patientsafety.pa.gov/ADVISORIES/Pages/200606_01b.aspx. Published 2006. Accessed August 16, 2020.
Tariq RA, Sharma S. Inappropriate Medical Abbreviations. [Updated 2020 Jan 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020.
