Error-Prone Abbreviation Elimination in Inpatient Areas:

• Percent of Inpatient Medication Orders with the Abbreviation “QD” 
• Percent of Inpatient Medication Orders with the Abbreviation “U” 
• Percent of Inpatient Medication Orders Lacking Leading Zeros
• Percent of Inpatient Medication Orders with Trailing Zeros

Patient Falls Reduction:

• Percent of Patients with Documentation of Fall Risk Assessment (Averaged)
• Percent of Fallers Identified as High Fall Risk (Averaged)
• Percent of Patient Rooms in Compliance with Safe Room Set-Up (Averaged)
• Percent of Total Patient Nights Sleeping Aid Given to High Fall Risk Patients 
• Percent of Falls with Sleeper Use within 12 hours 
• Percent Change in Fall Rates

Hand Hygiene Adherence:

• Percent of Instances Hand Antisepsis Indicated and Antisepsis Was Performed

Error-Prone Abbreviation Elimination:

Baseline information about current use was collected at each institution and shared, followed by the use of improvement cycles where each member enacted interventions thought to be most appropriate and effective for the respective organization. After several months, data was again collected and analyzed. Members then determined whether interventions found to be effective at one organization could be adopted by others to yield greater results in the next improvement cycle.

Educational/Awareness Interventions: 

• Sent letters on error-prone abbreviations to physicians and nurses from medical leadership/physician influentials.
• Placed educational articles on topic in internal publications, posters around the organizations, signs in nurse/physician restrooms and screensavers on computers reminding about error-prone abbreviations.
• Held discussions on the topic at key organization meetings.
• Incorporated education on error-prone abbreviations and medication ordering requirements into new employee orientation for pharmacists, nurses, and physicians. 
• Placed fluorescent stickers on charts with error-prone abbreviations in orders.
• Created an online PowerPoint educational module on the topic, which was made an annual requirement for faculty and house staff. Email reminders were used to contact individuals that had not completed the module.
• Held a Medication Safety Week that had activities addressing dangerous abbreviations. 
• Developed an abbreviations pocket card listing error-prone abbreviations and the preferred alternative, and distributed to house staff, attending physicians, new residents, and third-year medical students.

Structural Interventions:

• Created a separate order form for medications including a 'grid' to increase legibility, separate columns for medication, dose, route, frequency, and indications/other. Section on the form highlights inappropriate abbreviations and examples of correctly written orders.
• Included a laminated 'placemarker' (bookmark) that highlights inappropriate abbreviations. The placemarker goes in the patient chart in the orders section between the medication and other order sheet (forms face each other for writing ease).

Monitoring/Auditing Activities:

• Performed monthly or quarterly audits with reports to the physicians, nurses, and administrative groups. 
• Used Vice Presidents for Medical Affairs to follow-up with 'frequent offenders'.
• Had health unit clerks fill out an audit form each time they received an order with an inappropriate abbreviation. VPs for Medical Affairs collected forms daily and made immediate contact with prescribers who used inappropriate abbreviations.
• Performed a spot check on orders. Prescribers who used an inappropriate abbreviation received a letter from the department chair, VP for Medical Affairs, or physician leader.
• Posted results/feedback in the physician lounge and restrooms after each audit.

Enforcement Activities:

• Employed a “hard stop” to orders with error-prone abbreviations. If a medication order was received with a targeted inappropriate abbreviation, pharmacists required that the order be rewritten by the prescriber (verbal clarification allowed if off unit and documented).

Patient Falls Reduction:

Based on literature, best practices from other settings, and analysis of patient falls data from the hospitals, four priority areas were identified:

1. Assessment and identification of patients at risk for falls
2. Investigation into the impact of certain types of medications
3. Environmental modification of patient rooms, including the use of assistive and protective equipment
4. Provider and patient education

Numerous processes to prevent falls and harm at the hospitals were implemented. Significant progress in each priority area was achieved, beginning with the formation of a defined fall prevention team at each hospital.

• Ensured that all hospitals used an assessment tool to evaluate patients at risk for falls.
• Implemented policies where patients were assessed for risk during each shift and with change in condition, and those patients at risk are identified per procedure. Interventions were then put into place through nursing order sets and individualized assessment.
• Implemented a protocol for high-risk patients to reduce the use of sleeping aids which can cause confusion and impair judgment and mobility, thereby increasing the risk for falls.
• Implemented “Safe Room Set-Ups” and accompanying audits. Provided staff education on room set-up and made walking rounds to assess whether the conditions and arrangement of rooms, equipment, and furniture maximized safety for at-risk patients.
• Acquired, trialed, and educated staff members on further assistive/protective equipment such as motion sensing lights, bedside commodes, and hip pads. 
• Provided comprehensive fall prevention education to both patients and providers. One-on-one discussions and Grand Round presentations were employed for physicians and nurse representatives from each unit of each hospital. Provider staff were also brought together for a comprehensive education day on falls and fall prevention, while patients and families received brochures and provided feedback for signs and posters in patient rooms.

Hand Hygiene Adherence:

Infection control via hand hygiene was identified by the Madison providers as an area that would benefit from community-wide sharing of strategies across organizational lines. The group worked together to devise processes and strategies to gauge hand hygiene adherence, reduce barriers, and facilitate optimal use of hand hygiene practices.

• Shared previous efforts at each of the member organizations to promote hand hygiene.
• Developed and implemented a methodology to measure hand hygiene compliance on an ongoing basis via observation.
• Established observation structures at the participating organizations.
• Completed baseline data collection. 
• Trialed and selected waterless alcohol-based products, where necessary.
• Implemented or expanded and promoted the use of waterless alcohol-based products across the hospitals and clinics.
• Compiled observation data and provided results to staff, physicians, and organizational leaders each quarter.
• Provided heightened education on importance and proper hand hygiene techniques and waterless products.

Cooperation of the four hospitals and three medical groups has made patient safety a community-wide priority and offers the opportunity to develop and implement a safety culture, safety practices, and safety programs that go well beyond the scope of any single organizational effort. The reduction in inpatient use of error-prone abbreviations and patient falls, and the increase in provider hand hygiene adherence, are just several of the achievements that the collective efforts of the Madison Patient Safety Collaborative has produced.

Collaborative Improvement:

• Secure essential senior leadership commitment. Buy-in at the ‘top’ is critical in moving each initiative through member organizations.
• Start small. While establishing infrastructure, begin with smaller, manageable projects that will produce results more quickly as results are key to sustaining momentum and support.
• Recognize and manage the tension between research and improvement actions. While a scientific approach to patient safety solutions is important, timely results are critical to sustain enthusiasm. Frequent communication and revisiting of goals can help find an acceptable balance between action and research.
• Construct workgroups carefully. Considerable amounts of time can be lost if the ‘right people’—those that have the information, do the work, or can make the change—are not identified and involved early in initiatives.
• Balance being proactive vs. reactive. Great external activity in the area of patient safety can divert energy from a proactive focus. Again, frequent revisiting of goals and communication can help determine occasions when it is necessary to divert energies from being proactive in order to react.

Error-Prone Abbreviations Elimination: 

• Include non-physicians in the focus as other professionals may use abbreviations in handwritten patient-specific communications.
• Sanitize entity standing orders, protocols, and care pathways as they may contain dangerous abbreviations.
• Develop methods to educate and monitor new house staff and residents mid-year, where applicable.
• Note that information systems may contain inappropriate abbreviations in drop-down lists.
• Include some “teeth” to assist in behavior change.
• Note that projects such as this one, which involve changing ingrained behavior, take considerable time and effort... and don’t give up!

Patient Falls Reduction:

• Remember not to “put the cart before the horse.” An extremely valuable learning generated by this initiative was the need to focus on improving the assessment of patients at risk for falls and then communicate the status of these patients’ risk for falls to all parties—if a patient is not found to be at risk for falls, then carefully crafted interventions to prevent falls will likely not be put in place!

Hand Hygiene Adherence:

• There is great room for improvement based on the data. Observation can reveal a lot!
• Record adherence by categories of personnel so that efforts can be focused on areas requiring greatest improvement. 
• We gained essential organizational support for the implementation and expansion of the waterless alcohol-based products through the use of local data obtained via observation.

[Storyboard presentation at IHI's National Forum, December 2003]