Patient Safety Tip
of the Week
August 14, 2018
ISMP Canada’s
Updated “Do Not Use” Abbreviation List
ISMP Canada recently updated its “Do
Not Use” abbreviation list after doing an analysis of use of abbreviations in
healthcare settings (ISMP
Canada 2018). We like the basic tenet they use about abbreviations:
“…abbreviations, as well as symbols and dose designations, are only helpful when
their intended meaning is fully understood by all persons who will be
deciphering the information and when there is no potential for
misinterpretation.” ISMP Canada also stresses that inappropriate use of
abbreviations can be particularly hazardous at transitions of care (ISMP
Canada 2017).
The report particularly highlights
problematic use of route designations such as SL, SQ, and SC, and use of the
abbreviation “d” to represent days or doses, and use
of the ampersand symbol (&) to denote the word “and”.
SL (intended to mean sublingual), SQ
(intended to mean subcutaneous), and SC (also intended to mean subcutaneous)
can easily be confused with each other. In addition, “SQ” is sometimes
misinterpreted as a “5 every”.
The abbreviation “d” can be
interpreted as either days or doses. An example given was the order “Lactulose
15 mL po bid x 2d”. That order was intended to mean “for a duration of 2 doses”
but was mistaken as “for a duration of 2 days”.
They also note some abbreviations
that we, quite frankly, have not seen used. These include use of fractions
meant to convey information about duration or frequency. Examples given are #/24,
#/7, #/52 (denoting numbers per 24 hours, 7 days, and 52 weeks, respectively).
Another example was a direction for tapering a corticosteroid written as “2/7”
and then “1/7”. The intended meaning was that the prescribed dose be given
“for2 days” and then “for 1 day”, but the instructions were interpreted to mean
treatment “for 2 weeks” and then “for 1 week”, resulting in the patient
receiving a longer duration of therapy than was intended and experienced
adverse effects for which admission to hospital was required.
There is some good news, however,
about fewer dangerous abbreviations with the electronic medical record. The
current ISMP Canada bulletin notes that a recent Canadian hospital audit found
the rates of dangerous abbreviation use on electronic medication orders was
significantly less than on paper orders (0.4% vs. 24.1%, respectively). That is
reassuring because during one quality improvement implementation we found
numerous dangerous abbreviations in order entry screens and standardized order sets and some third party
vendor modules in an EHR (see our July 14, 2009 Patient Safety Tip of the Week
“Is
Your “Do Not Use” Abbreviations List Adequate?”). Dangerous abbreviations
also have a nasty habit of showing up in texted information and are one of our
many arguments that orders should never be texted.
The ISMP Canada list
(ISMP
Canada 2018b) and the even
more comprehensive ISMP (US) list (ISMP
2017) are considerably
longer than Joint Commission’s list of dangerous abbreviations. In that July
14, 2009 Patient Safety Tip of the Week “Is
Your “Do Not Use” Abbreviations List Adequate?”) we discussed that many
hospitals only adhere to the shorter Joint Commission “Do Not Use” abbreviation
list. In reviewing a hospital’s “Do Not Use”
abbreviation list for potential expansion, we found about 4% of total orders
had an abbreviation that appears on the ISMP list. However, about one in every
seven verbal or telephone orders contained such an abbreviation.
We take heart that the detrimental
effect of dangerous abbreviations has likely been mitigated somewhat as we’ve
transitioned from handwritten orders to electronically formatted orders. In
fact, some of the old ISMP samples of dangerous handwritten abbreviations seem
anachronistic when we show them in presentations. But they’ve been replaced by
the new kid on the block: texting. In our several columns (listed below) about
the dangers of texting orders, we cited use of dangerous abbreviations as one
example. In our January 30, 2018
Patient Safety Tip of the Week “Texting
Errors Revealed” we noted
common texting abbreviations are a threat. We’ve spoken before about the
example of a texted “2day” (meaning “today”) getting misinterpreted as “two daily” (ISMP 2009). ISMP provided some other examples of errors
related to texted abbreviations last summer (ISMP
2017b) and the latest ISMP survey (ISMP
2017a) uncovered a new one: the
text abbreviation “BTW” (meaning “by the way”) was misinterpreted as meaning
“twice daily”. And, while we were happy The Joint Commission saw the light and
did not reverse its ban on texting orders, the above mentioned ISMP survey
notes that the practice probably continues to exist to some degree despite
hospital policies banning it.
We recommend healthcare
organizations use the ISMP (US) list and perform due diligence in purging such
abbreviations that might be buried in their EHR’s in order sets (particularly
old ones or “personalized” ones if you allow them) or in third party vendor
software modules. Every organization also needs to periodically audit records
to see how often dangerous abbreviations continue to be used. You may be
surprised at what you find. We also suggest you look at the recommendations in
our December 22, 2015 Patient Safety Tip of the Week “The
Alberta Abbreviation Safety Toolkit”.
Some of our
previous columns on the impact of abbreviations in healthcare:
March 12, 2007 “10x
Overdoses”
June 12, 2007 “Medication-Related
Issues in Ambulatory Surgery”
September 2007 “The
Impact of Abbreviations on Patient Safety”
July 14, 2009 “Is
Your “Do Not Use” Abbreviations List Adequate?”
April 2015 “Pediatric
Dosing Unit Recommendations”
December 22, 2015 “The
Alberta Abbreviation Safety Toolkit”
See our other Patient
Safety Tip of the Week columns dealing with texting:
References:
ISMP Canada. Rearming the “Do Not
Use: Dangerous Abbreviations, Symbols
and Dose Designations” List. ISMP
Canada Safety Bulletin 2018; 18(4): May 30, 2018
https://www.ismp-canada.org/download/safetyBulletins/2018/ISMPCSB2018-05-DoNotUseList.pdf
ISMP Canada’s “Do Not Use Dangerous
Abbreviations, Symbols and Dose Designations” list. Original 2006, reaffirmed
2018.
https://www.ismp-canada.org/download/ISMPC_List_of_Dangerous_Abbreviations.pdf
ISMP Canada. Errors Associated with
Hospital Discharge Prescriptions: A Multi-Incident Analysis. ISMP Canada Safety
Bulletin 2017; 17(1): 1-5 January 31, 2017
https://www.ismp-canada.org/download/safetyBulletins/2017/ISMPCSB2017-01-HospitalDischargePrescriptions.pdf
ISMP (Institute for Safe Medication
Practices). List of Error-Prone Abbreviations. October 2017
https://www.ismp.org/recommendations/error-prone-abbreviations-list
ISMP (Institute for Safe Medication Practices). Safety Brief: “2day” gets “86ed.” ISMP
Medication Safety Alert! Acute Care Edition 2009; February 26, 2009
https://www.ismp.org/newsletters/acutecare/archives/Feb09.asp
ISMP (Institute for Safe Medication Practices). ISMP survey
shows provider text messaging often runs afoul of patient safety. ISMP
Medication Safety Alert! Acute Care Edition. November 16, 2017
https://www.ismp.org/resources/ismp-survey-shows-provider-text-messaging-often-runs-afoul-patient-safety
ISMP (Institute for Safe Medication Practices). The texting
debate: Beneficial means of communication or safety and security risk? ISMP
Medication Safety Alert! Acute Care Edition. June 29, 2017
https://www.ismp.org/resources/texting-debate-beneficial-means-communication-or-safety-and-security-risk
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