Stories category: HQCA Matters Blog

Mollie Cole is Director of Health System Improvement at the Health Quality Council of Alberta, and a registered nurse of many years.

As a registered nurse, I have encountered my fair share of abbreviations, symbols, and dose designations over the years. I’ve seen these used in treatment orders, prescriptions, medication administration records, care plans, clinical notes, and instructions to patients. I’m sure I was responsible for a few of these too. After all, some habits are hard to break without an occasional reminder.

That’s why, on behalf of the Health Quality Council of Alberta, I am pleased to share with you a few helpful tips and important reminders about the hazards of abbreviations, symbols, and dose designations in medical communications – and why it’s best to avoid them.

While it’s difficult to estimate the impact of this problem across Alberta, it’s not hard to find alarming studies that point to the danger of abbreviations, symbols, and dose designations in healthcare settings across the world.

One U.S. study of 30,000 medication errors, some fatal, showed five per cent were linked to abbreviations in notes.¹

As many of you in the healthcare sector already know communication shorthand commonly cause medication errors and adverse events. They can lead to the misinterpretation of instructions, especially if the language has multiple meanings or is not understood by all members of a healthcare team. And while the advent of electronic medical records and order sets have likely helped to mitigate abbreviation, symbols. and dose designations use in recent years, we know from audits that abbreviations in SMS texting are increasingly being found.

The Health Quality Council of Alberta has a mandate to promote and improve patient safety, person-centred care, and health service quality, and we’ve taken a keen interest in medication safety issues over the years such as the appropriate use of abbreviations, symbols, and dose designations.

This month, we launched a new page on our website, The Hazards of Abbreviations, Symbols, and Dose Designations, that highlights efforts healthcare providers and organizations can take to reduce the temptation to use shorthand in medical communications. This page replaces our abbreviations.hqa.ca site with a concise, updated look at this important topic.

One of the valuable resources you’ll find on our new webpage is a link to the Institute for Safe Medication Practices Canada (ISMP Canada) Do Not Use List – which is a regularly updated list of abbreviations and symbols that frequently create problems in medical communication and should never be used.

“The list is based on reports of medication errors to ISMP Canada,” said Carolyn Hoffman, CEO, ISMP Canada. “Through practitioner and consumer-lived experiences, we learn and share so that all of us can act to reduce the risk of this type of preventable harm.”

To learn more about this important topic, check out the new Hazards of Abbreviations, Symbols, and Dose Designations page.

HQCA Matters is published intermittently and presents the Health Quality Council of Alberta’s representative perspectives on topics or issues relevant to healthcare in Alberta.

¹ BBC NEWS | Health | Medical abbreviations ‘pose risk’

In 2017, a patient died after a medication error at Vanderbilt University Medical Center in the United States. We extend our sympathies to the family who suffered this tragic loss. Many healthcare professionals watched the case carefully, as the nurse who administered the wrong medication was criminally charged.

Our view

Criminalization of a medical error diverts attention from important aspects of patient safety that support our health systems to learn and improve.

No one is more equipped to make improvements to patient safety than healthcare workers, and the patients and families they serve. Healthcare workers are at the frontline delivering and witnessing care. As a result, they are in a unique position to identify potential and actual errors. They rely on safe venues to discuss unsafe situations, and require a healthcare system that is committed to acting on their findings. When we focus on individual blame and punishment, this can create a culture of fear that shuts down transparency and fosters an environment where healthcare workers no longer feel safe to voluntarily report potential and actual errors. This ultimately makes our health systems less safe.

A just culture

Organizations with a just culture see errors as opportunities to learn and to improve the healthcare system. Healthcare workers in a just culture trust their organization and feel that staff are treated fairly when they are involved in a patient safety event, including when they make an error. Reports of errors and patient safety hazards are important sources of information about weaknesses in the system, and are used to improve patient safety.

It is vital to promoting and improving patient safety that, as healthcare leaders, we ensure our organizations have a consistent, systematic and fair approach for gathering, organizing, and interpreting information about patient safety incidents and the actions taken by those involved. This begins with a thorough assessment of an incident using a systems-based approach that supports looking beyond the contribution of the individuals involved, and considers how complex interacting elements can influence care.

Tools such as the Just Individual Assessment (JIA) support a just culture and can be used to assess individual accountability within the context of the situation, including understanding contributing system factors.

The Health Quality Council of Alberta has created recommendations on what patients and families, healthcare workers, and organizations can do to foster a just culture. Now, more than ever, we need to commit to a just culture and we invite you to join us. Please check out our just culture website and the many resources available on this important topic.

Charlene McBrien-Morrison, Chief Executive Officer

HQCA Matters is published intermittently and presents the Health Quality Council of Alberta’s representative perspectives on topics or issues relevant to healthcare in Alberta.

Charlene McBrien-Morrison is the Acting Chief Executive Officer of the Health Quality Council of Alberta

More than 10,000 Albertans live in designated supportive living sites across the province. These sites provide accommodation, healthcare, and personal services to help residents remain as independent as possible and live their best lives.

Is that aim being met? What’s going well? And, how can the designated supportive living experience be improved?

In 2020 and 2021, the Health Quality Council of Alberta (HQCA) took a closer look at these questions in two separate deep dives:

• The Lived Experiences of Residents in Designated Supportive Living (January to March 2020) study
• Quality Exchange: Enhancing Resident and Family Experiences in Designated Supportive Living

Two common themes stood out for us.

A home-like environment
Interview after interview with residents, operators, and staff revealed the most positive experiences occur when residents feel seen and heard. Their experiences are honoured and understood. They have personal relationships with staff. And their new home, in designated supportive living, feels like their home.

Easy, right? Not at all.

We learned the transition into their new home in designated supportive living can be difficult, even at the best of times, as this move is often a sudden and major life event. It requires a period of adjustment for both residents and families.

During this transition, staff who are welcoming to the resident and their family can help. And personal relationships with staff matter. Residents appreciate friendly, patient, and cheerful staff who socialize, listen, and respect their choices and interests. For example, when staff at one site put a bird feeder on the window-sill of a bird-loving resident, her smiles spoke volumes. That was enough to feel like home for this long-time birdwatcher.

Similar stories bubbled to the surface frequently during our interviews as we set out to understand what drives a positive experience at these designated supportive living sites.

Listening
We also heard that listening is essential. Residents want input on decisions that affect them – from choosing their mattress to selecting meaningful social and recreational activities, and weighing in on the daily food menus. Importantly, it is not enough to just collect feedback. The real value is when designated supportive living sites act on feedback in conversation with residents and families.

Check out our work
To learn more about our findings in designated supportive living, I encourage you to review our work in this important area. As you’ll see, there is growing evidence of what constitutes the path to improved experiences for residents and families in designated supportive living.

Finally, we’d like to thank all of those who shared their experiences and thoughts with us. Your voices provided invaluable insights about how to keep improving designated supportive living across Alberta.

HQCA Matters is published intermittently and presents the Health Quality Council of Alberta representative perspectives on topics or issues relevant to healthcare in Alberta.

Ben Higgins, Lead, Health System Analytics

From my place in the world, it seems that any change to improve the quality of healthcare is going to increase cost. Can you help me understand how improvements can maintain, or better yet, lower the cost of healthcare delivery?

Geralyn, Health Quality Council of Alberta’s Patient and Family Advisory Committee Member

Hi Geralyn,

What a great question, and one with an answer I am very passionate about.

In order to answer this for you, it is important to understand variation, since reducing variation is one way to improve quality and lower cost.

What is variation? Put simply, it can be a different form or version of something. Or, it could be a change or slight difference we can observe or measure. For this conversation, we are going to talk about variation we can observe or measure. Everything around us that we observe or measure, varies. Variation is expected and some variation in healthcare is desirable, even essential, since each patient is different and should be cared for uniquely.

When healthcare decision-makers are trying to decide what to focus their attention and effort on, how do they know what variation is worth investigating?

To do this effectively, they need to understand the difference between common and special causes of variation.

Before we get into some healthcare examples, let me offer an analogy to help understand these ideas. Let’s think about variation and your commute to work.

You know about how long it takes for you to get to work each day. Let’s say it’s usually between 30-35 minutes to get from home to your work site. There is no way you can pinpoint the exact amount of time it will take because of common causes of variation (public transit arrival time, traffic light timing, a short distraction with your child while getting ready, etc.). You just expect that you will arrive sometime in that 30-35 minute range and accept that variation.

But then, one day, it takes 55 minutes to get to work. There was a lot more traffic on the roads and it turns out there was a broken traffic light at a huge intersection that caused a major back-up. This longer commute is well outside of that “typical” range and the traffic light problem is an example of what we would call a special cause of variation.

It is SPECIAL CAUSES of variation that healthcare decision-makers should be investigating.

Let’s look at an example from here in Alberta’s hospitals, from the Health Quality Council of Alberta’s FOCUS website. Below is a graph showing the length of patient hospital stay compared to the Canadian average for the Queen Elizabeth II Hospital in Grande Prairie. When you take a quick glance at this graph, does anything stand out as “unusual”?

Did you say the data points from October 2016 and January 2017? These look like really sharp spikes, right?

However, guess what? The lines for the upper and lower control limits actually show us the range for normal, common cause variation. Control limits are a statistical calculation that tells us what the boundaries are for when variation is in control (inside the limits) or out of control (outside the limits).

As we can see here, while those two spikes (October 2016 and January 2017) appear unusual, they are still inside the limits and would be actually considered a normal and expected amount of variation. So, while it might be tempting to make changes to processes after observing these spikes, we would not recommend investigating this variation further. Doing so would not likely improve the length of hospital stay (because the variation observed is within the expected limits for this system) and would lead the team in an unhelpful direction, wasting time, money, and other resources (e.g. people, supplies, equipment, etc.).

Special cause variation is where we recommend decision-makers focus their efforts on improving quality to make the most positive impact. Here are three of the most useful things we look for in the data before investigating special cause:

1. A single point outside of the control limits

2. Eight consecutive points above or below the mean line

3. Six consecutive points increasing or decreasing

When you see any of these three things happen with data, it’s worth looking into further.

To come back to your question, this example of the length of stay in the hospital is also a great one to talk about the relationship between quality and cost. When these hospitals see special cause variation for the better (what we see in both the examples for the Peter Lougheed Centre and the Grey Nuns Community Hospital above), they have an opportunity to investigate further, hopefully find out why there was an improvement, and then take steps to keep achieving the positive results (by sustaining, replicating, or scaling what caused the change). In this example, if these hospitals decrease their hospital occupancy rate (how many beds are in use) by shortening the length of stay, this could reduce the overall cost to the hospital and, ultimately, the system.

On the flip side of that coin, like in the early part of the Rockyview General Hospital example, when there is a special cause in the undesirable direction, they have an opportunity to investigate and correct the situation (by stopping or avoiding what happened). As you can see from their data, either improvements were made or circumstances shifted to where they have a second string of at least eight consecutive points below the mean. This sustained improvement offers another opportunity for investigation to learn from this and try to ensure the positive trend continues.

In fact, the Rockyview General Hospital data shows that this improvement was sustained for long enough that we could actually consider this to be a new normal for operations at this hospital. Considering this is the new normal, we recalculate the control limits to reflect this:

So, what does this mean? Well, let’s break it down in a way similar to how a quality improvement team at the hospital might look at this. The measure for “length of patient hospital stay compared to the Canadian average” is made up of two pieces:

1. The length of hospital stay for patients at Rockyview General Hospital and
2. The expected (average) length of hospital stay for similar patients in Canada.

When the measure is broken down into these pieces, we discover that the length of hospital stay for patients at Rockyview General Hospital has decreased slightly. Over this same period of time, the average for similar patients in Canada has increased slightly. Together, these changes lead to the shift you see at the Rockyview General Hospital.

From a cost perspective, it is likely that the slight decrease in length of hospital stay for patients at Rockyview General Hospital resulted in a lower average cost per patient (because they would have spent less time in the hospital) during the period of time from March 2017 to March 2018. And, if the hospital also saw a reduced occupancy rate during that same period, the overall cost to the hospital may have gone down as well.

So, as I mentioned before, it is very easy to get caught up in the “hot” issue of the day and start trying to fix or change something that was unusual and seemed like a big deal. This is why looking more closely at variation over time with these simple rules of thumb can lead to more meaningful quality improvement and uncover potential cost savings for Alberta’s health system. Those cost savings can be realized by focusing staff on chasing more variation where there is a real opportunity for improvement, not just where we have a “hunch” change is needed.

Hopefully this answered your question and helps you see why we find data so interesting here at the Health Quality Council of Alberta. If you have any other questions for us, please just let us know. Also, if you would like to read more about variation and get a bit more technical, I recommend checking out these great resources from the National Health Service (NHS) in England: here and here.

All data presented here is available on the Health Quality Council of Alberta’s FOCUS on Emergency Departments website, which is updated quarterly. If you would like to sign-up to receive notifications when new data is available, please click here.

For HQCA Matters updates, follow @Health Quality Council of Alberta on Twitter.

HQCA Matters is published monthly and presents the Health Quality Council of Alberta’s representative perspectives on topics or issues relevant to healthcare in Alberta.

Last year, the Fox Creek Healthcare Centre planned to design a COVID-19 resuscitation room in response to the pandemic.

Shelley O’Neill, External Nurse Investigator, saw this as an opportunity to apply her learnings from the Human Factors in Healthcare course offered by the Health Quality Council of Alberta and W21C.

“I used the skills and knowledge I gained during the Human Factors in Healthcare course to enhance efficiency and safety when resuscitating patients,” says Shelley.

Human factors is a scientific discipline that evaluates and understands human interactions in relation to other elements of a system. It’s a profession that applies theory, principles, data, and methods of design in order to reduce human error, increase productivity, and enhance safety and comfort.

The resuscitation room was designed and put to the test with several clinical simulations involving more than 15 staff members. This occurred in partnership with simulation consultants (Monika Johnson and Kristin Simard) from the Alberta Health Services North Zone eSim team. Movement patterns of individuals enacting the simulation scenarios were mapped out using a Link Analysis, a human factors method.

“Thanks to the Link Analysis we were able to identify potential issues and fine tune the design of the resuscitation room to minimize cross contamination so that patients and staff can remain safe,” said Shelley.

The team identified that the initial design required clinicians to move and cross paths frequently within the room to gather needed supplies. Modifying where supplies were stored, and defining the roles of the individuals involved in a resuscitation, helped create role specific zones within the room to minimize movement and potential cross contamination.

“Enacting the resuscitation scenarios also provided opportunities to practice and helped staff feel prepared and confident in their abilities,” added Shelley.

If you would like to be informed of the next Human Factors in Healthcare course offered by the Health Quality Council of Alberta and W21C please email Jonas.Shultz@hqa.ca.

The Health Quality Council of Alberta’s resources on human factors can be found here.

Andrew Neuner, Chief Executive Officer, Health Quality Council of Alberta 

There’s no shortage of things to think about these days if you are a family physician in Alberta.

Your practice is busy. The COVID-19 pandemic has added serious new patient questions. And in the background, we know the ongoing discussions with the Alberta government about the physician funding framework are likely on your mind.

Some of you may wonder why the Health Quality Council of Alberta chose now to release the 2020 Primary Healthcare Panel Reports.

The answer is we wanted to get this information – the most current and comprehensive data about patient panels – in your hands as soon as possible. And, frankly, some of you have been asking for it. Delaying the release runs the risk of making data less relevant.

I know all of you won’t have capacity to reflect on your panel data at this time. And that’s ok. It’s available for you to review whenever you’re ready.

With everyone focused on the COVID-19 response, the Health Quality Council of Alberta has put on hold – until further notice – our planned activities to promote these reports with physician and other healthcare audiences. That means we won’t offer webinars or pro-actively communicate about the reports in the near-term. There will also be delays in generating reports for new requestors.

There’s information on the Health Quality Council of Alberta website about what’s new with the 2020 data, and if you have any questions, please reach out to our team at primaryhealthcarereports@hqa.ca.

Thanks again for all you do to support patient safety and health service quality in Alberta.