Capitalization and punctuation
Q. Many of the listed abbreviations can be used in upper or lower case, with or without periods after the letters. If “Q.D.” is on our “do not use” list, can “QD” or “qd” be used?
A. An abbreviation on the do not use list should not be used in any of its forms—upper or lower case; with or without periods.
Clarifying orders
Q. What is the expectation for clarifying orders that contain “do not use” abbreviations?
A. Any time an order is unclear, it must be clarified with the ordering practitioner. This is an explicit requirement of the Medication Management standards (MM.04.01.01 and MM.05.01.01) and is addressed more broadly for other types of orders in the Leadership standards (LD.03.04.01). In the case of orders containing do not use abbreviations, the same requirements apply. That is, nurses and pharmacists exercise discretion to determine when an order is not clear and, in such cases, must contact the practitioner for clarification.
Noncompliant healthcare professionals
Q. What if some of our prescribers are unable or unwilling to stop using these prohibited terms or are unresponsive to calls from the pharmacy or other organization staff?
A. These are matters to be addressed and resolved by whoever has responsibility for oversight of prescribers’ activities in the health care organization. For hospitals, this will be the medical staff. For other types of health care organizations, it may be a professional staff, medical director, or administrator. Organization leadership should work with its medical staff or other professional oversight body/person to eliminate the use of prohibited abbreviations. Nurses’ and pharmacists’ responses to the use of prohibited abbreviations should be guided by patient safety considerations, not by an assigned responsibility for monitoring and modifying prescriber behavior. It is not the responsibility of nurses or pharmacists to manage the behaviors of prescribers. Joint Commission hospital standards assign to the medical staff the responsibility for overseeing the quality and safety of patient care, treatment, and services provided by practitioners privileged through the medical staff process and, in particular, providing leadership in activities related to patient safety and improving performance associated with significant departures from established patterns of clinical practice. For other settings of care, the Leadership standards assign comparable responsibilities for oversight.
Medical staff responsibility
Q. Which Medical Staff standards will be scored if the medical staff is not dealing with physicians who can’t or won’t stop using these prohibited terms?
A. This will be scored at MS.03.01.01: “The organized medical staff through its designated mechanisms provides leadership in activities related to patient safety” or at MS.05.01.01 EP 2: “The medical staff is actively involved in the measurement, assessment, and improvement of significant departures from established patterns of clinical practice.”
Other medication-related documentation
Q. It is clear why these terms are prohibited in orders but why are they also prohibited in “other medication-related documentation?” What’s the risk there?
A. The reasoning behind including “other medication-related documentation”, such as progress notes, H&Ps, nursing admission assessments, etc., in the scope of applicability of the “do not use” list was that these notes serve an important function of communication among caregivers and that a misinterpretation in this communication could lead to patient/client/resident harm. The prohibition applies to free-text entry into an electronic record just as for handwritten notes.
Transcribed reports
Q. With respect to dictated and transcribed documentation, whose responsibility is it to comply with the “do not use” requirements, the originator (dictator) or the transcriptionist or both? Should the transcriptionist be expected to edit these error-prone terms?
A. The primary responsibility for compliance rests with the author of the documentation. “Author,” in this context, includes a person who dictates documentation to be transcribed. We would consider it inappropriate for a transcriptionist to interpret or speculate on the intended meaning of any dictation that is not clear. If a “do not use” term is used in the dictation and the dictation is clear, that term should be transcribed as spoken, not translated or edited into its presumed meaning. If the dictation is not clear, then there must be a mechanism by which the originator can clarify it.
Contracted services
Q. Will an organization get a Requirement for Improvement (RFI) if a contracted service uses “do not use” abbreviations in its documentation in the medical records?
A. An accredited organization is held accountable for the performance of its “contracted services,” so if a contracted service uses “do not use” terms in the medical/clinical/case records of the organization’s patients/clients/residents, the organization will receive a RFI. In situations where the organization does not have a contractual or other accountable relationship, such as a home care service’s referring physicians, the organization will only be required to inform the practitioners about the safety goal expectations and encourage them to comply.