We haven’t done a full column on dangerous abbreviations since our July 14, 2009 Patient Safety Tip of the Week “Is Your 'Do Not Use' Abbreviations List Adequate?”. But dangerous abbreviations persist even as we’ve largely transitioned away from paper-based ordering systems to CPOE and e-prescribing.
Our interest was rekindled when we recently came across the Health Quality Council of Alberta (Canada) abbreviation toolkit (HQCA toolkit).
The Alberta abbreviations toolkit begins with a review of the literature, noting that the 5 abbreviations most often associated with errors are: “qd” (43%), “U” (13%), “cc” (13%), “MS” or “MSO4” (10%), and leading or trailing zeros (4%). It also provides links to the “do not use” lists from several quality and patient safety organizations. The toolkit also provides valuable materials such as focusing on high-alert medications or pediatric medications.
It then goes on to make recommendations about engaging the right people in your organization to implement a performance improvement initiative to reduce the use of dangerous abbreviations. These include recommendations about the role of leadership, clinical champions, and the actual implementation team. Further sections address measurement and planning for change. It has excellent sections on various strategies to use, audit and feedback, policies and guidelines, and education and training. Under strategies they include initiatives involving CPOE, forcing functions, standardization, pharmacy dispensing systems, and reminders. Forcing functions (or constraints) include not accepting any orders in which dangerous abbreviations appear.
In our July 14, 2009 Patient Safety Tip of the Week “Is Your 'Do Not Use' Abbreviations List Adequate?” we described our own experience with implementing a quality improvement project aimed at reducing the use of dangerous abbreviations. We began by noting that ISMP’s list of error-prone abbreviations, symbols and dose designations is considerably more comprehensive that Joint Commission’s list of “Do Not Use” abbreviations. We did a mini-survey of about 20 hospitals and could find none that used a list that went beyond Joint Commission’s minimum requirements. We jokingly refer to this as an “unintended consequence” of Joint Commission. Obviously, hospitals fear they will be cited if Joint Commission finds an occurrence of an abbreviation from an expanded list. But it’s really no joking matter. There are many potentially dangerous abbreviations on the ISMP list that are being condoned if an organization just goes with the Joint Commission minimalist list.
In reviewing a hospital’s “Do Not Use” abbreviation list for potential expansion, we found that about 4% of total orders had an abbreviation that appears on the ISMP list. More importantly, we found that about one in every seven verbal or telephone orders contained such an abbreviation.
So how does a healthcare organization go about expanding its “Do Not Use” list? The easy part is simply adopting all or part of ISMP’s list. The hard part is disseminating the new list, educating all appropriate healthcare workers about the list, implementing interventions to prevent their use, auditing and providing feedback, and measuring the impact. That process may take several months so setting a “go-live” date for policy implementation is wise when adopting such an expanded list. And it is critical to remember that these abbreviations do not just apply to orders. They apply to all forms of documentation, including history and physical exams, progress notes, discharge summaries, CPOE screens, standardized order sets, and electronic medical records, etc. They also should apply to your entire organization, both inpatient and outpatient. In particular, you also need to make sure that all your computer order entry screens do not contain any of the abbreviations you are adding to your list. Use of standardized order sets free of such dangerous abbreviations is a useful tool. Pay careful attention to all your pre-existing standardized order sets since we found these were a hidden source of many dangerous abbreviations. You would also be surprised at how often these abbreviations appear in software provided by third party vendors. Also, as we move into the “age of interoperability” you have to be wary that you don’t import documents and data from other hospitals and outside organizations that may contain some of the abbreviations you are trying to avoid.
After developing laminated pocket cards with the new list, developing screensavers with messages about dangerous abbreviations, and going to all departmental meetings (medical, nursing, and pharmacy) to discuss why we were doing this, we moved forward with the project. Every month the statistics were published and shared. The reports included the name of each provider who used one of the “do not use” abbreviations and these were shared with the department chairs and nursing supervisors. The medical director or department chair would then go over the abbreviations used with the individual physicians, advance practice nurses, or physician assistants. When meeting with them it is helpful to have examples (either from your own hospital or the literature) of a dangerous abbreviation that actually resulted in patient harm. We were able to keep the number of inappropriate abbreviations below the Joint Commission standard from the get-go and sustain that.
While we were largely able to keep dangerous abbreviations out of orders, it is much more difficult to keep them out of documentation like histories and physicals and progress notes. Some people have tried to downplay the importance of abbreviations in those documents, saying that they are dangerous only when in orders. That is absolutely not true. A discharge summary sent to a nursing home (or other post-discharge destination) with a discharge medication order that includes a dangerous abbreviation may well cause an error and patient harm at that next destination.
Propagation of such errors across transitions of care can also lead to patient harm. Physicians’ office notes, particularly handwritten notes, are notorious for containing dangerous abbreviations. In our June 12, 2007 Patient Safety Tip of the Week “Medication-Related Issues in Ambulatory Surgery” we noted the following story: “A patient came to an ambulatory surgery site for a procedure. Very little history had been provided prior to the patient’s arrival so on the day of the procedure staff asked the physician’s office to fax over some relevant office notes and the medication sheet. While hospitals have clearly begun to comply with the “do not use” abbreviation lists, most physician office notes are still replete with such abbreviations. The faxed notes were included in the facility medical record. The surgical procedure went well and the patient went home without incident or complication. However, 2 weeks later she was seen in the ER of the same hospital system for an unrelated problem. The patient’s primary physician was not available. The ER physician found in the patient chart copies of those office records that had been faxed in to the ambulatory surgery site. One of the medications listed in those records had a “qd” abbreviation that, perhaps in part because of fax artifact, looked like “qid”. The patient was admitted from the ER to the hospital and her maintenance medication that had been intended to be given once daily was now actually give four times daily. The error was not discovered until the patient developed symptoms of drug toxicity 5 days later. Well-performed medication reconciliation and compliance with the “do not use” list goal could have prevented this adverse outcome. But the case nicely illustrates how events in one part of the system can effect events in another part.” (See also our June 19, 2012 Patient Safety Tip of the Week “More Problems with Faxed Orders” for other examples of errors resulting from faxed orders.)
The abbreviations we had the most difficulty eliminating were the “>” and “<” symbols (“greater than” and “less than” symbols) and the “@” symbol. The latter, in particular, is an integral part of email addresses that are appearing more and more in various documents. So you may need to change your policy to allow the “@” sign when it is in an email address and only ban the “>” and “<” symbols when they are followed by a number.
Your monitoring process is also extremely important. Your Quality Improvement staff, medical records staff, and unit clerks can do spot checks of charts not only for orders but to make sure none of the documentation includes excluded abbreviations (also any charts you have selected for review via tracer methodology should be reviewed for unacceptable abbreviations). “Do not use” abbreviations are also one of the things we look for when doing patient safety walk rounds.
So don’t be satisfied that Joint Commission’s short list of dangerous abbreviations is all you need to meet. Do what’s right for patient care and look to eliminate all the abbreviations that have been shown to result in patient harm. Put together the right team and develop a plan to implement a more comprehensive approach to eliminating dangerous abbreviations. While Joint Commission always says it will hold you to “your own standards” we find it hard to believe they would actually ding you for going above and beyond and doing the right thing for patient care.
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”
HQCA (Health Quality Council of Alberta). Writing it out can save a life. Let's stop the use of abbreviations in healthcare. Abbreviations Toolkit.
ISMP. List of Error-Prone Abbreviations, Symbols and Dose Designations.
The Joint Commission. Official “Do Not Use” List.