Teaching Patient Safety

TMA-Developed Course Focuses on Preventing Medical Errors


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Medical Education Feature - October 2006  

ByKen Ortolon
Senior Editor  

Imagine the adverse consequences that could occur if you prescribed magnesium for a pregnant woman but the pharmacist reads your abbreviation for magnesium sulfate to mean morphine sulfate.

It sounds extreme, but health care organizations such as the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) say that is just the type of error that occurs all too frequently in the American health care system. And with the Institute of Medicine concluding that medical errors are the eighth leading cause of death in hospitals, Texas physicians says reducing those errors is critical for the health care of the nation and the safety of their patients.

That's why the Texas Medical Association is developing a new patient safety and medical errors prevention curriculum targeting both medical students and practicing physicians. TMA hopes it will raise awareness of problems that could be prevented through something as simple as avoiding easily misread abbreviations.

The curriculum already is drawing interest from health professionals across the nation. TMA officials believe the new program has great potential to reduce error rates in Texas because of widespread buy-in from the state's medical schools, other health institutions, and the physician community.

"It's critical for the health care of the country, for health care in the state of Texas, and for the safety of our patients to raise awareness with students, with residents, and with our physician population," said Don N. Peska, DO, a member of TMA's Subcommittee for Academic Physicians, which is developing the new curriculum. 

Focusing on Best Practices  

The effort to write a new curriculum began last fall during the term of TMA Immediate Past President Robert T. Gunby Jr., MD, who made patient safety the central theme of his presidential term.

Surendra Varma, MD, professor of pediatrics at Texas Tech University Health Science Center in Lubbock and a member of the academic subcommittee, says the initial charge was to develop a curriculum for medical students. But there also was considerable interest in the issue in graduate medical education circles.

"And, clearly, the issue has to be brought to the attention of the practicing physician, as well," added Dr. Peska, associate dean for educational programs and associate professor of surgery at the University of North Texas Health Science Center.

The curriculum will have six modules addressing communication issues, evaluation and decision making, treatment and medication, procedures and supervision, fatigue, and systems-based improvement.

Physicians from The University of Texas Medical Branch at Galveston, UT Health Center at Tyler, the University of North Texas, Texas Tech, and Texas A&M University System Health Science Center are drafting the modules. All of the state medical schools are represented on the academic subcommittee and will have input into final review and approval of the curriculum. Dr. Peska and Lisa Nash, DO, director of the family medicine residency program at UTMB and chair of the subcommittee, have led the effort to develop the curriculum.

The course will examine such issues as controlling medication errors, improving communication with patients of limited English proficiency, and eliminating latent errors built into patient care systems within hospitals. The curriculum also will address incorrect medication dosing, adverse drug interactions, surgical site identification, improper equipment maintenance, transfer of care, and other issues.

Each module will discuss best practices to prevent errors. One best practice that will be stressed is eliminating the use of potentially confusing abbreviations in writing medication orders, as recommended by JCAHO.

Dr. Peska says JCAHO has published a list of do-not-use abbreviations, "yet they still are in rather broad use because the word from the Joint Commission does not get out as well as it would from a physician-based organization. So we'll be calling attention to those specific abbreviations and demonstrate where they are confused and why they shouldn't be used." (See "Don't Use These Abbreviations.") 

Web-Based Learning  

The subcommittee planned to finish drafting the curriculum and begin beta testing by the end of August. Final subcommittee review of the program was slated for September, with distribution to Texas medical schools in October. The subcommittee plans to make the curriculum available to practicing physicians for continuing medical education (CME) credit on the TMA Web site. As of mid-August, however, the draft curriculum was still under review by TMA's Continuing Medical Education Department, which had not determined how many CME credit hours would be awarded for completing the course.

Dr. Peska says each medical school will determine how to use the course. He anticipates each one will make it a required part of its curriculum.

"At UNT, for example, my intent is for the program to be used by all of our students in their third year while they are on their family medicine rotation," Dr. Peska said.

He says medical school deans in Texas have endorsed the curriculum, and there is enthusiasm among medical educators elsewhere in the United States and Canada with whom he has shared some of the materials.

While the academic subcommittee hopes the curriculum will be widely used by residents and practicing physicians, Dr. Peska says its greatest impact may be in instilling error-preventing behaviors in medical students before they begin their medical careers.

"Awareness of the issues hopefully at the earliest level will create habits without having to change habits, so it will be much more effective," he said. "The habits the students will have at the very inception of their medical careers will be the correct habits, and they won't have to change the bad habits that they've acquired over the years."

Ken Ortoloncan be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at  Ken Ortolon.  


Don't Use These Abbreviations

The Joint Commission on Accreditation of Healthcare Organizations has published a list of abbreviations that should never be used.

Among them are:

  • U for unit, which can be confused for zero or cc;
  • IU for international unit, which can be mistaken for IV or 10;
  • MS or MSO 4 for morphine sulfate and MgSO 4 for magnesium sulfate, which can be confused for each other;
  • QD for once each day and QOD for every other day;
  • SC or SQ for subcutaneous, which can be confused for sublingual;
  • TIW for three times a week, which can be misinterpreted as three times daily; and
  • > for greater than, and < for less than because they can be mistaken for an L or a 7.

The entire list is posted on the JCAHO Web site at www.jointcommission.org. Click on the Patient Safety tab at the top of the page and look for Safety Initiatives.

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