Abbreviations: Short-cuts To Failure?
By Robert Batton, R.Ph., Department of Pharmacy, Baylor University Medical Center

Medication errors have received widespread attention in the literature. Articles related to patient safety are frequently disseminated by accreditation, professional and regulatory organizations and contain guidelines for how healthcare professionals should amend their practice. It is because patients of all ages have been exposed to the deleterious effects of failures during the medication use and changes have been relatively slow in health care systems that regulatory agencies are implementing standards that affect each health care professional.

The decision of a physician to order a medication initiates a series of steps that, if they become misaligned, can lead to improper care of the patient. While abbreviations utilized in prescribing or transcribing orders can save time and are commonly used in medical documentation, these orders are frequently misread or misinterpreted.

It has been reported that as much as 15% of the medication error reports received by the NCC MERP (National Coordinating Council for Medication Error Reporting and Prevention) have occurred because of illegible handwriting, problems with leading and trailing zeros, misinterpreted abbreviations, and incomplete medication orders. The JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and the ISMP (Institute for Safe Medication Practices) have published numerous articles discussing that the ongoing use of potentially dangerous abbreviations, dose expressions, and/or poor penmanship continues to be utilized in the medication use process and lead to reports of patient harm.

In 2003 and 2004, the JCAHO published the National Patient Safety Goals (NPSG). Each of these goals addresses specific types of healthcare errors that plague our nation's health care system. JCAHO Sentinel Event Alerts have served as the main source for these goals. Included in these goals is the necessity for institutions to "improve the effectiveness of communication among caregivers." This goal requires that each facility develop a list of abbreviations, acronyms, and symbols that should not be used. On November 6, 2003, the JCAHO published a list of nine unapproved abbreviations that must be adopted by institutions. Recently, the Joint Commission announced that all accredited health care facilities will be evaluated for compliance with these goals.

Beginning in 2004, the JCAHO will be assessing a "special Type-1 recommendation" to institutions not complying with these goals. If during a survey the JCAHO determines that greater than 10% of medication orders contain elements of the unapproved abbreviation list, the organization will be given this score. Recently, the Committee on Pharmacy and Therapeutics at Baylor University Medical Center (BUMC), in order to promote patient safety and comply with the National Patient Safety Goals, has developed a list of abbreviations, symbols, and acronyms that are considered "unapproved" in hand written medication orders. All healthcare providers should not utilize these abbreviations. This table illustrates the list of unapproved abbreviations, symbols, and acronyms for BUMC and provides the rationale for not utilizing them.

Examples of problematic abbreviations include "U" for "units", or "µg" for "micrograms", or "QD" for "every day". When "U" is handwritten, it can look like the number zero and result in a ten-fold overdose. When "QD" is used in handwritten orders, it is sometimes interpreted as "QID" or even "QOD. When the abbreviation "µg" is utilized instead of "microgram", it can lead to a thousand-fold overdose if it is misinterpreted as "mg". The use of a leading decimal point (e.g. .1 instead of 0.1) without a leading zero or the use of trailing zeros (e.g. 1.0 vs. 1) is also very dangerous. The decimal point is at times not seen in handwritten or faxed copies of orders and could lead to a 10-fold dosing error.

In addition to the "minimum required list" provided on page 13, Chart 2 should also be considered when expanding the "Do not use" list.

Also, the Institute for Safe Medication Practices (ISMP) has published a list of dangerous abbreviations relating to medication use that it recommends should be explicitly prohibited. This list is available on the ISMP website: ismp.org.

To illustrate "real-life" examples, here, find two handwritten orders obtained from the BUMC Medication Variance Reporting System. These two events demonstrate how handwriting and Latin abbreviations can contribute to a medication error.

Orders for Prednisone and Toprol XL were interpreted and transcribed into the patient care system as "QID" (four times daily) while the prescriber intended the drugs to be given "QD" (daily). Recently, the Department of Pharmacy displayed these errors (in much larger size) and very few healthcare professionals were able to correctly identify the schedule on these two orders. Characteristically, while groups of people attempted to identify the intention of these orders, they "huddled up" and as a group "interpreted" the orders.

By complying with the alternatives to the unapproved abbreviations (listed above), all health care professionals will help our patients obtain the medication and dose that was intended. Eliminating error-producing habits can help reduce the need to contact prescribers or transcribers if order clarification is needed.

What can the ordering physician do to minimize the opportunity for error? Use the complete spelling for a drug name. Do not use abbreviations when ordering medication! They should take time to write legibly or they should expect phone calls from other healthcare professionals if orders are illegible or incomplete. They can also avoid phone calls by complying with the recommendations found in the Unapproved Abbreviations.
References : jcaho.org & ismp.org