Medication orders no place for individuality
June 1, 1997
Medication orders no place for individuality
Patients endangered by whimsical ordering habits
There’s a time for individual expression and a time to conform. And surely, from the standpoint of medication orders, it’s best to do the latter. That’s what a team from Promina Gwinnett Health System in Lawrenceville, GA, learned when they sought to reduce medication errors by standardizing symbols and abbreviations as much as possible.
The team found that some doctors were using trademark abbreviations, even symbols that sometimes incorporated Latin or Greek.
The pharmacy discovered the high incidence of unapproved abbreviations by conducting a random analysis of medication order sheets, explain Charles A. Krivenko, MD, vice president for system clinical services. During a six week period, the pharmacy analyzed about a thousand sheets and found that about half contained a source for a possible error, such as illegible handwriting and incomplete dosage instructions.
Room for error
The biggest category for potential error was in the use of unapproved abbreviations. Twenty-seven percent of error-possible sheets contained an unapproved symbol or some other short-hand notation. These unorthodox instructions included such things as "IVP" for IV push, "Neb" for nebulizer, "H/A" for headache, "MSO4" for morphine sulfate, and an asterisk or degree mark to signify "hour."
After identifying the problem, the hospital focused on changing the writing behavior of a group of doctors responsible for many of the potential errors.
"We isolated the 20 top stylistic’ practitioners," Krivenko says. "We told them what they do. We sent them a letter. I called each one." Krivenko says he tried to put a non-punitive, educational spin on the effort.
Second audit a disappointment
Unfortunately, it didn’t work. "We did another audit of 350 order sheets and found no significant improvement," Krivenko says: Doctors continued to use stylistic notations, despite being told of the potential danger.
The disregard doesn’t surprise Jeffrey Bernstein, PhD, a workplace psychologist in Philadelphia, who suggests that these small expressions of individuality may be a response to doctors’ waning control in today’s health care environment.
"I think the current health care situation is making problematic a baseline characteristic of physicians that is, a need for autonomy," Bernstein says. Put more poignantly, Bernstein says all people feel a need to make their mark on the world, and with physicians being told what to do on every level, stylistic writing may be a quiet way to rage against the machine, so to speak.
Krivenko has a less esoteric explanation for stylistic writing: The long and varied course of education doctors go through. "There’s a culture in medicine to write, initially, in Latin," he says. "They tend to pick up Latin and chemical notations. They use lots of trailing zeroes because they go through scientific classes that require use of three decimal places. I think it’s a potpourri of things internalized as students. The little circle they use for hours, for example, I don’t know where that came from."
The slower the better
As far as legibility goes, Krivenko says studies have shown that if doctors slow down, they write neater. But there’s not much chance of the pace easing up in today’s health care environment. That’s why Krivenko thinks automation is the only real solution for stylistic writers.
In the meantime, Promina Gwinnett is planning a new tact for dealing with with its stylish writers: Direct, quick confrontation. For example, if a physician writes 1 mg of Coumadin as 1.0 mg, a pharmacist will immediately let the physician know that the 1.0 could have been mistaken for a 10, and a patient might have died as a result.
One final tip
One easy way to cut down on medication errors is to change the kind of paper and pens physicians use for ordering. Unlined paper is best, because decimal points and sevens can become blurred into lines. As for pens, one simple rule: No felt-tip markers allowed. They don’t penetrate triplicate paper well. One hidden source for felt-tip pens: pharmaceutical sales representatives. Let them know you want regular pens or nothing at all.
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