leap s newsletter
TRANSCRIPT
Dear Colleagues,
In this issue of Leaps, I will discuss some of the aspects of quality
and safety at AUBMC, about the work we are doing or activities
we engage in to enhance care and ensure we meet the highest stan-
dards of quality. AUBMC’s Administration is especially passion-
ate about ensuring that high-quality care is available to everyone,
irrespective of their socio-economic status or insurance coverage.
In today's health care environment, as we know, there is an expec-
tation that hospitals, doctors, nurses, pharmacists and other health
care providers will work together, as a Team, to create opportuni-
ties to ensure the delivery of high quality care. Teamwork, coordination of care and communication
are critical for achieving the desired outcomes. The Medical Center has adopted a performance improvement strategy to achieve our goals of:
Patient-Centered Care
Quality and Safety
Service Excellence
Quality, a fundamental in our care:
In March of this year, we have launched multidisciplinary High Performance Clinical initiatives that
will advance quality standards and evidence based medicine. These initiatives include “Performance
Improvement” committees that are currently working on developing order sets, guidelines and path-
ways to standardize and improve care in cardiology, critical medicine, hematology, emergency medi-
cine, pediatric and medication management.
Safety, a priority in our care:
Creating a positive culture of safety is one of the key challenges that healthcare organizations face.
Therefore, we are working on having a robust event reporting system that encourages AUBMC staff to
report not only adverse events but also near misses and close calls. Our ultimate goal is better care, not
only lower numbers of events.
While often difficult for those directly involved in safety events, it is important for our hospital com-
munity to be as open and as transparent as possible about all safety-related issues, to ensure that we
can learn from and find ways to prevent such errors from occurring. Anytime an event occurs, we will
institute a multidisciplinary team to carefully and thoroughly review and analyze the event closely. We
are always looking for ways to improve our system and practice and not blame the individuals.
Delivering the highest quality and safest care is our commitment to patients that both defines us and
enables us to thrive as an institution.
Petra Khoury, Pharm D Clinical Executive Administrator
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Editor: Dr. Rami Mahfouz
Layout: Ms. Shatha Abi Ghanem
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The only way to assure quality and excellence is to give people
something to believe in
Quality and Safety at Core of Care Redesign at AUBMC
LEAPSLEAPS Newsletter
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Q u a l i t y , A c c r e d i t a t i o n a n d R i s k M a n a g e m e n t P r o g r a m
Featured Article 1
Documentation in Phy-
sician Orders 2
Compliance with Initial Assessment by Medical
Staff for Inpatients 3
Documentation of Sur-
gical Site (Laterality) 3
Risk Management Cor-
ner 3
Use of Error-prone abbreviations, symbols and dose designations
4
Miscellaneous 4
Inside This Issue:
Volume 6, Issue 3
Layne Longfellow
Happy Holidays from the Quality Accreditation and Risk Management
December 2011
Proper documentation in physician orders is a requirement by the national (MOPH, MS.5.1, MS.5.3), and international (JCI,
MMU.4.1, MCI.13) accreditation standards, as well as the AUBMC policies and procedures (multidisciplinary policies on Physician
Orders and on Abbreviations).
A review was conducted by Ms. Rasiel Kabli, a 3rd year Health Information Management and Technology student from Dammam
University, whom I was honored to supervise during her training at our Program. The aim of the review was to check the physician
documentation on the Order Sheet, particularly for the presence of the physician name / stamp, date and signature, abbrevia-
tion use, allergy documentation, and proper correction of errors.
A random sample of 48 patient discharges was drawn out of the AUBMC June 2011 discharges. After excluding 10 pre-printed
orders, 38 medical records were reviewed, which contained 226 order sets (defined as a group of orders written at one time and
signed together).
The physician name was present in 134 out of the 226 order sets (59%); however, the name was legible only in 66 (49%) of those.
Compliance with the availability of name / stamp was 60%.
Of the order sets, 55% were signed by the physician; however, compliance dropped to 15% when checking for the availability of
the name / stamp AND signature. Five order sets (2%) did not contain any physician identifier. Compliance rates of 99%-100% were
noted for date and time documentation, and proper correction of error, versus 53% for allergy documentation.
More than half of the order sets (133) contained abbreviations, out of which 62 (47%) contained unapproved ones, including 34
error-prone and 29 unclassified abbreviations. The most common error-prone abbreviations were “D/C” and abbreviated drug
names, while the mostly used unclassified abbreviation was “PRN”.
Recommendations:
1. Quality, Accreditation & Risk Management Program:
Unify the requirements on abbreviation use in Physician Orders & Abbreviations policies (DONE)
Update the Physician Orders policy to request the physician pager number in the order set to help in physician identification
Update the lists of approved & of error-prone abbreviations to clarify the possibility of use of unclassified abbreviations
Re-assess compliance with the policies
2. Chief of Staff: Send a circular to the Medical Staff to:
Promote the legibility of physician orders including the physician name
Request the physician pager number in the order set
Allow a significant space between orders to avoid signing over the previous physician’s signature
3. Medical Records Committee:
Provide separate columns for the physician name & signature on the Order Sheet
Conduct educational sessions to Medical Staff about appropriate documentation in physician orders
Lina Mekawi, MS Senior Data Analyst
Page 2 L E APS NE W SL ETT E R
Documentation in Physician Orders
If there are no common
values, there can be no
image of the future.
Robert Bundy
Laterality pertains to a side of the body i.e., left or right according
to Joint Commission International (JCI). In relation to the AUBMC
multidisciplinary policies on pre- operative/ pre-procedure verifi-
cation (COP-MUL-003), the laterality of the planned procedure
shall be specified. If pertinent, the correct person, procedure, and
site/side shall be verified in all settings.
According to JCI: The International Patient Safety Goal number 4
states that “correct site, correct procedure and correct patient
surgery shall be ensured”. In addition, the Lebanese Ministry of
Public Health Accreditation MOPH standard on patient safety (PS
8.9) emphasizes: “Identification of right patient, right side, and
right procedure in surgery”.
A compliance review was done in September 2011 to assess the
degree of medical and nursing staff compliance with AUBMC
policies on pre- operative/ pre-procedure verification (COP-MUL-
003) and Abbreviations (MCI-MUL-006), international patient
safety goal and national standards. The overall compliance rate
has slightly increased from 68 % (June 2011) to 79%. Our aim is
100%!
Layal Mohtar, MPH , CPHQ
Quality Review Analyst
Risk Management Corner
Page 3 L E APS NE W SL ETT E R
The IHI Improvement Map
The Institute for Healthcare Improvement (IHI) launched the Improvement Map which is a free, interactive, web-based
tool designed to bring together the best knowledge available on the key process improvements that lead to excep-
tional patient care. IHI experts selected a total of 73 processes and prepared the individual elements of implementa-
tion, expected outcomes, and metrics for measurement of each process.
The Improvement Map can be an instrumental tool in guiding your quality improvement journey. No matter where you
are on your improvement journey, you’ll be able to find yourself in the Improvement Map and chart a path to achieve
your aspirations.
The Improvement Map aims to help hospitals to:
Provide safer care
Make patient care transitions smoother
Effectively lead improvement efforts
Reduce costs and increase quality
All hospitals around the world can join the IHI in this vibrant network,
so that we can all benefit from the collective knowledge and energy.
Khalil Rizk, MHA, CPHQ
Quality, Accreditation and Risk Manager
Documentation of Surgical Site (Laterality)
Initial assessment is a JCI and MOPH requirement for all patients
admitted to the Medical Center for the first time. The AUBMC
policy on “Assessment and Reassessment of Inpatients” (AOP-
MUL-003) defines the scope and components of patient assess-
ment for each clinical specialty. The policy also specifies the
timeframe for completing the assessment.
During the month of September 2011, a retrospective review
was conducted on patients admitted to the AUBMC during the
month of August 2011 to check for evidence of initial assess-
ment and completeness of documentation by the medical
staff. A Random sample of 79 (3%) medical records from 11
clinical specialties was reviewed.
Some common problems were identified in the assessment
forms of the clinical specialties: The use of unapproved abbre-
viations, improper correction of error, completion of the assess-
ment items by drawing a line through all the items instead of
documenting each item, and missing signature of the attend-
ing physician on the initial assessment forms. Furthermore, some
initial assessment forms were completed by medical students
and they were not countersigned by the resident or the attend-
ing physician. It is also worth mentioning that most of the spe-
cialties complete the initial assessment forms within 4 hours
when they document the time on the initial assessment form.
In conclusion, the initial assessment forms for all the clinical spe-
cialties have to be revised to ensure compliance with the re-
quirements. Moreover, it is important to ensure that medical
staff perform proper documentation including name, signature,
date, and time on the assessment forms.
Lisa Sekilian, BSN, MPH
Accreditation Compliance Officer
Compliance with Initial Assessment by Medical
Staff for Inpatients
Access to Care and Continuity of Care
(ACC)
Admission and Care of Pre-Admission
Unit Patients (ACC-MUL-010)
Care of Patients (COP)
Child Protection (COP-MUL-024)
Government, Leadership and Direction (GLD)
Non-Punitive Reporting (GLD-MUL-002)
Paging Medical Staff (GLD-MST-003)
Facility Management and Safety (FMS)
Use of Personal Non-Medical Appliances (FMS-SFT-005)
Lina Mekawi, MS Senior Data Analyst
The Joint Commission recommends to minimize (as much as possible) the use of abbreviations and encourages all the accred-
ited organizations to develop and implement “A not to use list of abbreviations”. The Institute for Safe Medication Practices
“ISMP” prepared the list of Error-Prone Abbreviations, Symbols and Dose Designations to prevent frequent misinterpretations that
are known to cause harmful medication errors. ISMP recommends that abbreviations shall not be used when communicating
medical information. The error-prone abbreviations, symbols and dose designations used are: S/C, SQ, Sub Q, S.Q, SC, QD,
QOD, Qd, qd, qD, QHS, μg, mcg, D/C, U, cc, OS, OU, >, / (slash mark), MgSO4 and chemical symbol (NaHCO3) used in drug
name.
A compliance review to check the degree of use of error-prone abbreviations and to ensure compliance with the policy on
abbreviations (MCI-MUL-006) was conducted by the Quality, Accreditation and Risk Management Program on a random sam-
ple of 113 medical records representing (4%) of patients discharged in October 2011. The results showed that in 89% of the re-
viewed medical records one or more error-prone abbreviations (from the above list) were used in the physician orders.
Physicians are urged to avoid the use of the error-prone abbreviations in their orders.
Hayat Al Kai Quality Review Analyst
V OLUM E 6, ISSU E 3 Page 4
Staff Awareness Questionnaire
Questionnaire #31
Dareen Hajj Sleiman Clinical Educator
Diana El Banna Medical Staff Officer
Domna El Zayed Registered Nurse
Mariana Jaafar Research Assistant
http://staff.aub.edu.lb/~webaccrm/
AUBMC Policy and Procedure Manuals Available Online: https://his.aub.edu.lb/
Talented Writer… Send Your
Quality Related Stories to
Quality, Accreditation and Risk Management Program
Use of Error-Prone Abbreviations, Symbols and Dose Designations in Medication Orders
Have 10 people form a 4-3-2-1 hori-
zontal pyramid (arranged like bowl-
ing pins). Tell them to reverse the
apex and the base of the pyramid
by moving only three people.
Do not give up too easily! Check the
solution in next issue.
The big winners were Joseph NassifJoseph Nassif, MD from the OB/GYN Department and Shawki NassarShawki Nassar, RN from the Nursing Ser-
vices. They received a 220$ worth gift while the other win-ners received various gifts.
Questionnaire #32
Samar Nassif Patient Education Coordinator
Hisham Bawadi Nurse Manager
Hanadi Massalkhi Registered Nurse
Ahmed Kaskas Registered Nurse
List of NEW Policies