Remember all of those “do not use” abbreviations?
I wrote a post about them a loooong time ago, but since then things have changed.
We went from written medical charting to almost exclusively computer [hack hack] generated medical records.
So the whole Joint Commission issue about a “>” looking like the number “7” or the notation “cc” looking like two extra zeroes is – or at least should be – a moot point.
And I still believe that if someone can’t tell the differences in dosing between “MSO4″ and “MgSO4″ then they shouldn’t be prescribing or administering those medications. Again, it should be a moot point since orders have to be made from dropdown lists.
But some organizations don’t understand the concept of “moot.” Rules just keep
At the start of my shift, a very pleasant member of the chart review team was waiting to talk to me. This same member of the chart review team had reportedly chastised a nurse because she hadn’t completed a “medication reconciliation” on a young multiple trauma patient that was flown out of our ED to a regional trauma center less than 30 minutes after arriving. Because obviously whether the patient medication list states that he took Motrin and Zyrtec on an as-needed basis was going to have a profound effect on whether he would survive his rib fractures, hemopneumothorax, and open femur fracture. In fact, wasting time documenting nonessential information such as ASA scores and medication reconciliations will very likely have a detrimental effect on patient outcomes.
As a side note, it is rather sad that government regulations force hospitals to hire multiple full-time employees – mostly trained nursing staff – whose sole job is to comb through the work of those caring for patients in order to pick minute errors making no clinical difference in a patient’s treatment or outcome from a document that is likely thousands of words long. Then, instead of just making the changes themselves, they have to find whomever failed to properly document this nonessential information, interrupt them during their clinical duties, and stand over their respective shoulders while they correct their “errors.” Again, the documentation changes rarely if ever have any beneficial effect on patient care and often cause delays in patient care due to all the requirements for extraneous information. If the chart reviewers instead were able to use their time to provide care to the patients, hospitals would be safer places.
My chart review error was heinous. I wrote “cc” instead of “ml” in one of my notes. It wasn’t even an order or a prescription. It was a notation of how much medicine a child was taking prior to coming to the emergency department.
“Dr. WhiteCoat, you’re going to need to change this in your note. It says “cc” and should say “ml.”
“I can’t change it in my note. The note has been finalized and can’t be edited.”
“You’ll need to put an addendum clarifying the notation, then.”
“It is on the Joint Commission’s ‘unapproved abbreviation’ list. The notations can be confused. In this case, the ‘cc’ could be confused with ’00.'”
“You’re kidding me.”
“No. It has to be changed.”
Then that little gremlin whispered something in my ear.
“I’m not sure what the problem is. The notation says ‘ml.'”
She stopped and read through the chart.
“No. Right there. It says ’15 cc’. See it?”
“Yes. I see where you’re pointing. It says ’15ml.'”
She started getting frustrated and raised her voice.
“No, Dr. WhiteCoat. It clearly says ’15 cc.'”
“OK. If it clearly says ’15 cc’ then there’s no chance of people confusing it with ‘1500’ – which by the way would mean that the child was taking a liter and a half of medicine every day. So remind me again what the problem is.”
She gathered her papers and left in a huff.
The nurse who had been chastised earlier gave me a thumbs up sign.
Fifteen minutes later I get a phone call from the head of the medical staff.
“Will you just make the change, please?”
All in the name of patient safety.