That’s Bad Form!
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Transcript of That’s Bad Form!
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That’s Bad Form!Michael Ben-Aderet, Tim Cushing,
Derek Huang, Alvin Liu, John Sy, and Summer Williams
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Why?• Too many forms• Forms need to be updated• Incomplete forms• Too many medical errors• Nurses paging housestaff
about orders• Housestaff unsure about
available options
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Goals
• Simplify Forms• Improve Patient
Safety and Care• Improve Housestaff
Satisfaction• Meet Government
Requirements
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Plan
• Review all forms that housestaff use• Highlight necessary ones that need to be
updated• Tackle those that are used the most
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Old Cardiology
Form (OV1399)
From 2007
CLINICAL INFORMATION???
MEDICATIONS???
I‘M AN INTERN…HOW THE HECK SHOULD I
KNOW WHAT TEST TO ORDER???
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Process
• Reviewed form with Cardiology Dept• Came up with form specifications:– Patient information • Name• Medications• HISTORY
– Test information• Cardiology WILL change test depending upon
clinical history and reason for exam
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Form Cycle
Specifications
Form Design
ReviewTesting
Implementation
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To be smart?
• What is a smart form?– A form that can be filled out online and/or printed
• Improve legibility• Improve accuracy of information
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Now, that’s a smart form…
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New Cardiology
Form (2013)
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Review of Cardiology Form
• Improved transfer of information to cardiology department
• Enabled optimal testing to occur• Reduce exposure to unnecessary testing
• No longer need old EKG form – especially as outpatient, just ask clerk to enter into system and patient should present OV card to cardiology department
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Medicine Admission Form (OV2428)
• Top 3 forms used by housestaff• Consistently being reviewed and updated• …but missing a lot
• A comparison of forms:– OVMC – 3 pages– Harbor – 6 pages
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Specifications• Each section of the form with different
specifications depending upon the department involved… for example:
Clerks, Phlebotomy, Laboratory
Medical Administration, Patient Safety, JCHAO
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Things we cannot change…
• Handwriting – PLEASE WRITE LEGIBLY
• Dosing errors – PLEASE CHECK YOUR RXs
• That the RNs will STILL page you about your patient…
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Old Order Form
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Basic Information – Section 1
• ICU Added – no longer a separate form• Holdover box added – nurses know who to page (especially for
hospitalist holdovers)• Admission location clear• Level of care change indication
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Diagnosis and Assessment - Section 2
• Specified Isolation• What old chart???• Don’t forget our neutropenic patients!
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Physician Notification – Section 3
• What the heck is a SUPO Form? – JC requirement• STANDARD VITALS!!! • Don’t forget to change them if needed!
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Activity and Diet – Section 4
• Fluid restriction box
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Consult and Treatment – Section 5
• Occupational Therapy• IV therapy: continuous vs fixed amount• Respiratory therapy• Chlorhexidine baths for patients on chemotherapy or with central
venous catheters (CVCs) – for nursing
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Labs/Test – Section 6
• More tests, especially for ICU• No more STAT labs – abuse of STAT power• Phlebotomy Information
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VTE Prophylaxis – Section 7
• Meets all government requirements• Don’t forget to select a contraindication!
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Medication Reconciliation – Section 8
• Start, continue, stop?• Don’t forget hold parameters and PRNs• Home medications MUST be listed in H&P
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Typical Olive View Patient…
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Common Medications – Section 9
• All those and more!... Night float will thank you for that Miralax!• GI prophylaxis• Prevent therapeutic duplication• Those pesky nebs!
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Insulin – Section 10
• Can’t help you there…• But at least you don’t have to write “units”!
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Pain medications – Section 11
• The pen is mighty…but checkboxes are easier!• I didn’t know we had (insert pain med here)!• What is that dose of IV dilaudid again? 2 mg?!• Avoid therapeutic duplication problem
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Code Status – Section 12
• Only Attendings can sign DNR/DNI orders anyway…
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New Order Form
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Achievement Highlights
• Eliminated ICU order form• Consistent vital signs for patient safety• Reduce use of STAT labs• Reduce therapeutic duplication• Encourage proper use of DVT and GI ppx• Eliminate confusion with med rec section• Brought in further commonly used
medications
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Assessment of New Form
• Asked housestaff to fill out the old and new forms from a mock case
• Timed themselves filling out both forms• Answered 5 questions based on old and new
forms
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Survey Results (n=5)
Old New
Average Time (minutes) 6.0 5.3
General Satisfaction 7.0 8.6
Error Prevention 7.8 9.0
Efficiency 7.0 8.4
Areas of Improvement 7.8 5.8
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Committees
• Both forms approved by MRRC (Medical Records Review Committee)
• Admission Form must go to P&T committee to be approved (for medications) in early July
• Will uploaded to the intranet for housestaff to use after P&T committee review
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Ongoing activities…
• Radiology form update• Nuclear Medicine form elimination• Insulin Form update
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Acknowledgments
• Dr. Mark Richman• Dr. Mike Rotblatt• Dr. Leland Powell• Dr. Susan Stein• Dr. Katherine Yu• Dr. Dennis Yick• Dr. Nick Kamangar• Dr. Robin Waschner
• Anna Ziouzina• Laura Sarff• Karla Nungaray• Joy Mata• Lori Smith• Alma Alvarez• Jan Love• Carlos Carranza
• Clerks• Nurses• Respiratory Therapy• Housestaff