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 and the even more comprehensive ISMP (US) list 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. I
In our January 30, 2018 Patient Safety Tip of the Week “” 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.
December 22, 2015 Patient Safety Tip of the Week “”.
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”
April 2015 “Pediatric Dosing Unit Recommendations”
December 22, 2015 “”
See our other Patient Safety Tip of the Week columns dealing with texting:
ISMP (Institute for Safe Medication Practices). Safety Brief: “2day” gets “86ed.” ISMP Medication Safety Alert! Acute Care Edition 2009; February 26, 2009
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
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