Medical staff members who use error-prone abbreviations or fail to sign their verbal orders within 48 hours must complete an online educational module to retain staff privileges, according to a peer committee of physicians.

The mandate from the Health Information Management Committee of the Medical Staff was approved as hospital and medical staff policy effective June 1.

The verbal order and unapproved abbreviations policies are included as part of the hospital’s effort to conform to National Patient Safety Goals, a JCAHO initiative.

The committee noted its charter includes a focus “on preventable errors and error prone processes in practitioner communication. Two areas where we have not achieved full compliance are counter-signature for verbal orders and use of unapproved abbreviations.”

The State of California requires verbal/telephone orders to be counter-signed by the prescribing practitioner within 48 hours.

“To promote compliance the medical staff is requiring the completion of Healthstream [online educational] modules which will be assigned to physicians who are non-compliant,” the committee continued. “This is meant to be a brief non-punitive educational experience to explain why this is necessary and assist you in remembering to sign verbal orders promptly in the future and to eliminate the use of unapproved abbreviations.”

“The JCAHO mandate and state law are important, but really the most important reason for complying with these initiatives is patient safety and quality,” said Kevin Tabb, chief quality and medical information officer. “This safety concern is the primary reason why both of these issues are included with JCAHO’s National Patient Safety Goals.”

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For a general discussion of patient safety initiatives, see an interview on page 4 with Kim Pardini-Kiely, SHC’s new director, Quality Improvement and Patient Safety. Her department is responsible for supporting physician and hospital efforts to ensure clinical quality and regulatory compliance.