Brunetti, Santell and Hicks (2007) recently carried out a study which examined medication abbreviation errors in great detail, scrutinizing their content, source and effect. Their report analyzed medication errors reported to a national medication error reporting system, which was employed by close to 700 faculties, between the years 2004 to 2006. It was found that in all the medication errors, about 30,000 were caused by use of abbreviations and that the most commonly occurring ones were due to the use of qd (43.
1% of all errors). Other frequent errors were due to the use of short-forms such as u for units, cc for ML, MSO4 or MS for morphine sulfate, and decimal errors. Errors during prescription accounted for the largest portion (81%) of all errors. Based on the results of this study, it can safely be concluded that abbreviation errors are a cumbersome and pervasive problem which must be tackled, because the benefit of saving a few seconds can not be equated to the possible loss of a precious life (Ulrich, 2007).
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Institute for Safe Medication Practices (ISMP) are both involved in restriction or outright elimination of many common abbreviations because they pose risks to patients. Eliminating abbreviations will definitely lead to fewer errors, and to understand this one need only consider examples of the harm this menace has led to. Brunetti, Santell and Hicks (2007) quoted the following examples in their paper: 1.
A patient on hemodialysis, 62 years of age, was ordered acyclovir as treatment for a viral infection. The order, written as acyclovir (unknown dose) with HD was interpreted inaccurately as TID or three times per day. This particular patient, because of hemodialysis, could only be administered acyclovir once daily, after adjustment for renal impairment. When the patient received thrice the suitable dosage, it caused mental decline, delirium and consequent death. 2. A patient was prescribed a hydromorphone epidural, with the order written as 2 ?
g/mL. However, the pharmacist entered the order as 500 mg in 250 mL, prepared the order, and on the label, wrote 2 mg/mL. The error chain did not stop here: the nurse then interpreted the labeled medication inaccurately and administered to the patient dosage which with a 1,000-fold disparity than what was needed. The patient could not withstand this dosage and developed substantial respiratory depression and a weakened cardiac function, which required serious measures to correct the damage.
ISMP president Michael Cohen reported the use of qd which means everyday, but is often mistaken for q. i. d. meaning four times a day as the most common problem, and one of the most dangerous. From the above examples and incidences of countless other events where abbreviations have led to errors in medication, it is obvious that if the use of abbreviations is eliminated, it will lead to reduced risk to patient safety. Cohen said, We have been promoting a long list of abbreviations that should never be used because they are so dangerous.
How much longer does it take to write d-a-i-l-y on an order instead of q. d. in the cause of safety? Why risk anything unnecessary when youre dealing with patients? (Gebhart, 2005) While the incidences of harm to patients might not be that common, that should not be reason enough for this practice to continue uncontained. Any possibility of patient harm should be avoided and prohibition of abbreviations is definitely a step towards saving lives.
Since Brunetti, Santell and Hicks (2007) found that abbreviation errors mostly originated from the point where prescriptions were made than from any other node. Written policies are definitely needed to restrict the usage of abbreviations. The Joint Commission affirmed its do not use list of abbreviations in May of 2005 which was a welcome step in removing the originating causes of the error, i. e. abbreviations, rather than depending on quality control measures to prevent the from reaching the patient.
The ISMP also published a list of error-prone abbreviations, symbols, and dose designations which were frequently misinterpreted and also proposed safer alternatives (ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations). There is definite need of policies which minimize the potential for error and maximize patient safety. For example, there are countless cases reported where problems relating to insulin dosage have been traced back to the interpretation of a U as a zero.
Another potentially harmful writing practice is the use of trailing zeros or when a leading decimal point is used without a leading zero. If these orders are misinterpreted, dosing errors of up to 10-folds can take place and it is essential that there is education and standardized policies which illustrate the dangers of use of abbreviations. The JCAHO and ISMP have been active in this regard. The former has specified in its manual that medication orders should contain the degree of accuracy, completeness, and discrimination necessary for their intended use.
It has also identified some strategies which health care organizations should implement such as developing a proper list for all prescribers of prohibited abbreviations/symbols, policies to make sure the list is consulted and the staff abide by with this regulation, and a policy which ensures that even if an unacceptable abbreviation or symbol is used, the order is verified with the prescriber before it is filled (Medication errors related to potentially dangerous abbreviations). Some abbreviations however, are acceptable.
These include those which are on any organization-specific approved list or which are not ambiguous and have a single meaning, or context, and can be understood across the board, as they are intended. However, these will be fewer, and hence it is more practical to simply limit the use of abbreviations in general and eliminate certain abbreviations in particular. This will definitely warrant a change in practice, but this is necessary in order to reduce confusion and the potential for mistakes.
The standardization that will be achieved by following the recommendations of the Joint Commission and the ISMP will play a vital role in reducing the incidence of errors caused by these abbreviations. Every clinician and member of the staff of any healthcare organization is at the risk of making a harmful mistake when an easily misinterpreted acronym, abbreviation or symbol is used (Acceptable Abbreviation List). While organizations such as the JCAHO and ISMP are devoting their efforts to medication error prevention, a lot still needs to be done to bring down the error rate.
Every participant in the field must realize their responsibility and ensure that they do not value their time, habit or convenience over a human life. Also efforts must be made to ensure compliance with the initiatives and standards of the above mentioned organizations as well as a proper system of accountability in healthcare organizations by reviewing patient care records and determining the degree of adherence to these recommendations.
Acceptable Abbreviation List. The Joint Commission. Retrieved February 5, 2008 from the Joint Commission website: www.ismp.org/Newsletters/ambulatory/Issues/Abbreviations.pdf