Error Prone Abbreviations

Error Prone AbbreviationsTo Abbreviate or Not to Abbreviate?Abbreviations are often used when writing orders to indicate dosage times, frequencies, routes, and other information about the med. However, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) recommends not using abbreviations when writing med orders because of the high amount of errors that have occurred related to use of abbreviations. Can you think of any complications related to misinterpreted abbreviations?JCAHO steps inJCAHO developed the official do not use list of abbreviations in 2004.

These abbreviations should NOT be used when documenting med orders or other medication information.JCAHOs Do Not Use List

Abbreviation: q.d. or QDMeaning: Every Day Misinterpretation: q.i.d (four times daily)Correction: Daily

Abbreviation: U or uMeaning: UnitMisinterpretation: The number zero causing a tenfold overdose. (For example, 10u could be seen as 100!)Correction: UnitAbbreviation: q.o.d. or QODMeaning: Every Other DayMisinterpretation: q.d. or q.i.d.Correction: Every Other DayAbbreviation: MS, MSO4, MgSO4Meaning: Morphine Sulfate and Magnesium SulfateMisinterpretation: Confused for one another.Correction: Write out morphine sulfate and magnesium sulfate

Abbreviation: IU Meaning: International UnitMisinterpretation: IV or the number 10.Correction: Write out international unit

Abbreviation: Trailing Zeros.Example: 4.0 mgMisinterpretation: 40 mgCorrection: 4 mg Abbreviation: Lack of a Leading Zero.Example: .5 mgMisinterpretation: 5 mgCorrection: 0.5 mgDont let this be you

Risky BusinessAn article entitled Abbreviations: Speed or Risk? on the website allbusiness.com, states that According to the Institute of Medicine (IOM) of the National Academies, there are more than 7,000 deaths a year due to medication errors. Mistakes can occur anywhere in the medication-use system, from prescribing to administering a drug in a variety of settings (hospitals, outpatient clinics, nursing homes, home care, etc.) Potentially confusing abbreviations are part of this problem. A major cause for concern.The use of abbreviations has received much attention as one of the major causes of medication errors. The risk of misinterpreting an abbreviation is even greater with handwritten orders, as the handwriting may be illegible.In addition to JCAHO, several other organizations including the Institute of Medicine, American Society of Health-System Pharmacists, Food and Drug Administration, National Coordinating Council for Medication Error Reporting and Prevention, and American Hospital Association, warn that the use of inappropriate abbreviations may lead to confusion and communication failures.Use caution when U use abbreviations!According to the website http://www.ismp.org/tools/abbreviations/ One of the most common but preventable causes of medication errors is the use of ambiguous medical notations. Some abbreviations, symbols, and dose designations are frequently misinterpreted and lead to mistakes that result in patient harm. They can also delay the start of therapy and waste time spent in clarification. Not just handwritingNot only should you NOT handwrite dangerous abbreviations, you shouldnt type them either. Abbreviations in print could still be misinterpreted.They could be copied onto handwritten orders.And they may give them impression that it is okay to use such abbreviations, even when its not!Some examples:

The 4u could be misinterpreted as 44 instead of 4 unitsExamples:

Instead of taking one tab of KCl every day, this patient could be getting it four times a day!

A PSA from http://www.ismp.org/tools/abbreviations

Reducing the Use of Unsafe Abbreviations: A StudyAn article titled Educational interventions to reduce use of unsafe abbreviations looked at the strategies used to reduce the usage of unsafe abbreviations at a level 1 trauma center at Detroit Receiving Hospital. Six abbreviations were deemed as unsafe by the patient medical safety committees: 1) U for units, 2) g for microgram, 3) TIW for three times a week, 4) the degree symbol for hour, 5) Trailing zeros after a decimal point, and 6) the lack of leading zeros before a decimal point.Data on abbreviation use was collected by examining copies of patients order sheets which are sent from nursing units to the pharmacy for processing. Reducing the Use of Unsafe Abbreviations: A StudyFor 8 months data was collected during three 24-hour periods each month, with 7-10 days between each period.A data collection sheet was developed to assist in documenting the number of opportunities for each unsafe abbreviation and the actual incidence of each.Educational strategies were developed and began to be implemented a month after the start of the study.These strategies included: inservice education programs for the medical, pharmacy, and nursing staffs; laminated pocket cards; patient chart dividers; stickers; and interventions by pharmacists and nurses during medication prescribing.

Reducing the Use of Unsafe Abbreviations: A StudyDuring the 8 month evaluation, 20,160 orders were reviewed, representing 27,663 opportunities to use a designated unsafe abbreviation.

Educational interventions successfully reduced the overall incidence of unsafe abbreviations from 19.69% to 3.31%

Reducing the Use of Unsafe Abbreviations: A Study

Results of the study.In conclusionMedication errors related to the use of unsafe abbreviations is dangerous AND preventable.Educating hospital staff on this matter is necessary to ensure that these errors do not occur.JCAHOs do not use list is just the minimum. There are other risky abbreviations that you should consider not using. Check your agencies policy and procedure manual, they may have their own additional list of abbreviations not to use.And lastlyWhen in doubtWRITE IT OUT!!!Questions:1. What is the appropriate way to chart every day?

A. QDB. q.d.C. dailyD. QRST Questions:1. What is the appropriate way to chart morphine sulfate?

A. Morphine SulfateB. MSC. MSO4D. The pain pill Questions:What is the appropriate way to chart four tenths of a milligram?

A. 4/10ths mgB. 0.4 mgC. .4 mgD. 4mg Questions:Who can name 3 abbreviations on the JCHAO do not use list?

Questions: Why is it dangerous to use the do not use abbreviations?Questions:Where should you check to find out additional abbreviations you shouldnt use at your agency?